The Role of Health Extension Workers in Linking Pregnant Women With Health Facilities for Delivery in Rural and Pastoralist Areas of Ethiopia

Inequalities in use of hospitals for childbirth among rural women in sub-Saharan Africa: a comparative analysis of 18 countries using Demographic and Health Survey data

INTRODUCTION

Rising facility births in sub-Saharan Africa (SSA) mask inequalities in higher-level emergency care-typically in hospitals. Limited research has addressed hospital use in women at risk of or with complications, such as high parity, linked to poverty and rurality, for whom hospital care is essential. We aimed to address this gap, by comparatively assessing hospital use in rural SSA by wealth and parity.

METHODS

Countries in SSA with a Demographic and Health Survey since 2015 were included. We assessed rural hospital childbirth stratifying by wealth (wealthier/poorer) and parity (nulliparity/high parity≥5), and their combination. We computed percentages, 95% CIs and percentage-point differences, by stratifier level. To compare hospital use across countries, we produced a composite index, including six utilisation and equality indicators.

RESULTS

This cross-sectional study included 18 countries. In all, a minority of rural women used hospitals for childbirth (2%-29%). There were disparities by wealth and parity, and poorer, high-parity women used hospitals least. The poorer/wealthier difference in utilisation among high-parity women ranged between 1.3% (Mali) and 13.2% (Rwanda). We found use and equality of hospitals in rural settings were greater in Malawi and Liberia, followed by Zimbabwe, the Gambia and Rwanda.

DISCUSSION

Inequalities identified across 18 countries in rural SSA indicate poor, higher-risk women of high parity had lower use of hospitals for childbirth. Specific policy attention is urgently needed for this group where disadvantage accumulates.

Unpacking the challenges of fragmentation in community-based maternal newborn and child health and health system in rural Ethiopia: A qualitative study

INTRODUCTION

In Ethiopia, country-wide community-based primary health programs have been in effect for about two decades. Despite the program's significant contribution to advancing Maternal Newborn and Child Health (MNCH), Ethiopia's maternal and child mortality is still one of the highest in the world. The aim of this manuscript is to critically examine the multifaceted fragmentation challenges of Ethiopia's Community Health Workers (CHWs) program to deliver optimum MNCH and build a resilient community health system.

METHODS

We conducted a qualitative case study in West Shewa Zone, rural Ethiopia. A purposive sampling technique was used to recruit participants. Data sources were two focus group discussions with sixteen CHWs, twelve key informant interviews with multilevel public health policy actors, and a policy document review related to the CHW program to triangulate the findings. Thematic analysis of the qualitative data was conducted. The World Health Organization's health systems framework and socio-ecological model guided the data collection, analysis, and interpretation.

RESULTS

The CHWs program has been an extended arm of Ethiopia's primary health system and has contributed to improved health outcomes. However, the program has been facing unique systemic challenges that stem from the fragmentation of health finance; medical and equipment supply; working and living infrastructures; CHWs empowerment and motivation, monitoring, supervision, and information; coordination and governance; and community and stakeholder engagement. The ongoing COVID-19 and volatile political and security issues are exacerbating these fragmentation challenges.

CONCLUSION

This study emphasized the gap between the macro (national) level policy and the challenge during implementation at the micro (district)level. Fragmentation is a blind spot for the community-based health system in rural Ethiopia. We argue that the fragmentation challenges of the community health program are exacerbating the fragility of the health system and fragmentation of MNCH health outcomes. This is a threat to sustain the MNCH outcome gains, the realization of national health goals, and the resilience of the primary health system in rural Ethiopia. We recommend that beyond the current business-as-usual approach, it is important to emphasize an evidence-based and systemic fragmentation monitoring and responsive approach and to better understand the complexity of the community-based health system fragmentation challenges to sustain and achieve better health outcomes. The challenges can be addressed through the adoption of transformative and innovative approaches including capitalizing on multi-stakeholder engagement and health in all policies in the framework of co-production.

Community-based newborn care intervention fidelity and its implementation drivers in South Wollo Zone, North-east Ethiopia

Community-based newborn care (CBNC) has been implemented in Ethiopia across the maternal, neonatal, and child health continuum of care with the goal of lowering newborn mortality. However, neonatal mortality rate in Ethiopian is among the highest in the world. Why neonatal mortality remains high in the face of such effective interventions is the issue. As a result, the authors claim that it is unknown whether the planned intervention is carried out effectively or not. The purpose of this study was to investigate the fidelity of community-based newborn care intervention and its implementation drivers. Multicenter community-based mixed method study was employed on 898 postpartum women, 16 health extension workers (HEWs) and 10 health posts to evaluate CBNC intervention fidelity. Structured questionnaire and facility audit checklist was used to collect quantitative data. In-depth interview technique was used to explore lived experiences of HEWs on CBNC implementation. CBNC intervention fidelity was computed as a composite index of the product of program coverage, frequency and contents. Multilevel linear regression model with adjusted β-coefficients at P-value of 0.05 and a 95% confidence interval (CI) were used to declare a significant relation between CBNC intervention fidelity and its implementation drivers. Interpretative phenomenological analysis was employed for qualitative data analysis. CBNC intervention fidelity was found to be 4.5% (95% CI: 3.6-5.4) with only two women received the intervention with full fidelity. The overall CBNC intervention coverage was 38.4% (95% CI: 35.2-41.6). Only 8.1% and 1.5% of women received all CBNC interventions with recommended frequency and content, respectively. HEWs knowledge of danger sign was significant facilitator while lack of: health center's feedback, related short-term training, health development army support, health center staff's technical assistance to HEWs and shortage of medical equipment supply were barriers for CBNC intervention fidelity. In conclusion the CBNC intervention fidelity was too low in this study. This indicates that CBNC intervention package was not implemented as envisioned implying an implementation gap. All implementation drivers were poorly implemented to result in improved fidelity and intervention outcomes.

Factors associated with comprehensive knowledge of antenatal care and attitude towards its uptake among women delivered at home in rural Sehala Seyemit district, northern Ethiopia: A community-based cross-sectional study

Background

Despite the current sustainable development goal period (i.e. SDG 3), the prevention of maternal and neonatal mortality is not satisfactory in Ethiopia. Keeping women knowledgeable about antenatal care and maintaining a positive attitude towards its uptake, particularly in the marginalized rural community is crucial. However, evidence regarding the knowledge and attitude of women towards antenatal care uptake is scarce. Therefore, this study aimed to assess factors affecting comprehensive knowledge of antenatal care and attitude towards its uptake among women delivered at home in rural Sehala Seyemit district, northern Ethiopia.

Methods

A community-based cross-sectional study was conducted from September 1^st to October 15^th, 2020. A multi-stage sampling technique was used to select 653 women. The data were collected using a semi-structured interview guide. Data were entered into EPI INFO 7.1.2 and analyzed by SPSS version 25. Both bivariable and multivariable logistic regression analyses were undertaken to identify factors associated with women’s knowledge of antenatal care and attitude towards its uptake. The level of significant association in the multivariable analysis was determined based on a p-value of < 0.05.

Results

Women’s knowledge of antenatal care and positive attitude towards its uptake was 56.5% and 75.2%, respectively. Older age (AOR = 7.2; 95% CI: 3.43, 15.1), media exposure (AOR = 3.69; 95% CI: 2.41, 5.65), history of abortion (AOR = 11.6; 95% CI: 3.3, 14.6), time to reach health facility (AOR = 4.58; 95% CI: 3.05, 6.88), and history of obstetric danger signs (AOR = 7.3; 95% CI: 3.92, 13.64) were factors significantly associated with knowledge of antenatal care. Furthermore, higher decision-making power (AOR = 8.3; 95% CI: 4.8, 13.83), adequate knowledge of antenatal care (AOR = 2.2; 95% CI: 1.26, 3.71), delivery attended by health extension workers (AOR = 2.3; 95% CI: 1.1, 5.1), and media exposure (AOR = 2.27; 95% CI: 1.30, 3.97) were predictors of a favorable attitude towards antenatal care utilization.

Conclusion

Although the majority of women in the present study had a favorable attitude towards antenatal care uptake, their knowledge level was inadequate. Strengthening access to transportation, mass media, involvement in household decision-making, and encouraging women to deliver at a health facility by a skilled provider may increase women’s knowledge and attitude towards antenatal care uptake, thereby improving maternal healthcare service uptake.

Community perception of barriers and facilitators to institutional delivery care-seeking behavior in Northwest Ethiopia: a qualitative study

Background

Institutional delivery care-seeking behavior is considered a crucial step in preventing maternal and child death. However, the barriers and facilitators related to institutional delivery care-seeking behavior in the study area were not studied very in-depth. Hence, the current study aimed to explore barriers and enablers of institutional delivery care-seeking behavior in Northwest Ethiopia.

Methods

A descriptive phenomenological qualitative inquiry was used. The data was collected by using a piloted interview guide. We collected data using in-depth interviews among women and men; and key informant interviews from the Female health development army and health extension workers in November and December 2019. Framework analysis was utilized for the analysis of the data.

Results

This study found out the potential factors which hinder and facilitate institutional delivery. The barriers to institutional delivery included the belief that pregnancy and childbirth are normal and business of women’s, women’s preference of home delivery with traditional attendants, family influence, fear of bad behavior of health care workers, and lack of resources. The facilitators were free maternal services (ambulance services and maternity services), having the experience of safe childbirth at health facilities, and women’s health development army linkage with health extension workers.

Conclusion

This study provides evidence that low-risk perception of home delivery, socio-cultural influences, service provision modalities, and financial factors were the determinants of institutional delivery service use. Therefore, a stage-matched intervention shall be designed to improve the uptake of institutional delivery service use.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12978-022-01497-5.

Institutional delivery plays a critical role in the prevention of maternal death and improves newborn health. Although most of maternal health services were free of charge in Ethiopia, institutional delivery is low in the rural Central Gondar zone of Wogera and East Dembiya districts. Low institutional delivery was the major contributors to high maternal deaths in Ethiopia. This low utilization of institutional delivery in the study area could also affect the health status of the newborn.

This study was conducted to explore the community perceptions of the socio-cultural and health service factors influencing institutional delivery. Overall, 30 interviews (18 In-depth and 12 Key-informants) were conducted in the selected rural kebeles of Wogera and East Dembiya districts to collect data from women and their husbands for in-depth interview; and key informant interviews from the female health development army and health extension workers.

The facilitators of institutional delivery categorized into three themes; namely, free maternal services (ambulance services and maternity services), having the experience of safe childbirth at health facilities, and women’s health development army linkage with health extension workers.

The socio-cultural factors impeding institutional delivery categorized into five themes; namely, the belief that pregnancy and childbirth are normal and business of women’s, women’s preference of home delivery with traditional attendants, family influence, fear of bad behavior of health care workers, and lack of resources.

Conducting a stage-matched intervention shall be designed to improve the uptake of institutional delivery service use in Wogera and East dembiya districts.

Exploring complementary and competitive relations between non-communicable disease services and other health extension programme services in Ethiopia: a multilevel analysis

Background

Ethiopia has recently revitalised its health extension programme (HEP) to address the rising burden of non-communicable diseases (NCDs). We examined the effects of existing essential HEP services on the uptake of NCD preventive services.

Methods

We applied a mixed-effect non-linear model with a logit link function to identify factors associated with a community resident’s probability of receiving NCD prevention services through the HEP. The data were drawn from the Ethiopian HEP assessment Survey conducted in all regions. The analysis included 9680 community residents, 261 health extension workers (HEWs), 153 health posts, 119 health centres, 55 districts and 9 regions, which we combined hierarchically into a single database.

Results

In the 12 months before the survey, 22% of the sample population reported receiving NCD preventive service at least once. The probability of receiving NCD prevention service increased by up to 25% (OR=1.25, CI 1.01 to 1.53) if health centres routinely gathered NCD data from health posts and by up to 48% (OR=.48, CI 1.24 to 1.78) if they provided general (ie, non-NCD specific) training to HEWs. NCD preventive service uptake also increased if the HEW held level IV qualification (OR=1.32, CI 1.06 to 1.65) and lived in the community (OR=1.24, CI 1.03 to 1.49). Conversely, if facilities delayed general performance reviews of HEWs by a month, uptake of NCD prevention services decreased by 6% (OR=0.94, CI 0.91 to 0.97). We observed that better HIV/AIDS programme performance was associated with a lower uptake of NCD preventive services (OR=0.15, CI 0.03 to 0.85).

Conclusion

Despite efforts to improve NCD services through the HEP, the coverage remains limited. A strong HEP is good for the uptake of NCD preventive services. However, integration requires a careful balance, so that the success already recorded for some existing programmes is not lost.

Multilevel determinants of community health workers for an effective maternal and child health programme in sub-Saharan Africa: a systematic review

Background

Countries in sub-Saharan Africa (SSA) continue to have the highest maternal and under-five child deaths in the world. The ongoing COVID-19 pandemic is amplifying the problems and overwhelming already fragile health systems. Community health workers (CHWs) are increasingly being acknowledged as crucial members of the healthcare workforce in improving maternal and child health (MCH). However, evidence is limited on multilevel determinants of an effective CHWs programme using CHWs’ perspective. The objective of this systematic review is to examine perceived barriers to and enablers of different levels of the determinants of the CHWs’ engagement to enhance MCH equity and a resilient community health system in SSA.

Methods

We systematically conducted a literature search from inception in MEDLINE complete, EMBASE, CINAHL complete and Global Health for relevant studies. Qualitative studies that presented information on perceived barriers to and facilitators of effectiveness of CHWs in SSA were eligible for inclusion. Quality appraisal was conducted according to the Critical Appraisal Skills Programme qualitative study checklist. We used a framework analysis to identify key findings.

Findings

From the database search, 1561 articles were identified. Nine articles met the inclusion criteria and were included in the final review. Using socio-ecological framework, we identified the determinants of CHWs’ effectiveness at 4 levels: individual/CHWs, interpersonal, community and health system logistics. Under each level, we identified themes of perceived barriers such as competency gaps, lack of collaboration, fragmentation of empowerment programmes. In terms of facilitators, we identified themes such as CHW empowerment, interpersonal effectiveness, community trust, integration of CHWs into health systems and technology.

Conclusion

Evidence from this review revealed that effectiveness of CHW/MCH programme is determined by multilevel contextual factors. The socio-ecological framework can provide a lens of understanding diverse context that impedes or enhances CHWs’ engagement and effectiveness at different levels. Hence, there is a need for health programme policy makers and practitioners to adopt a multilevel CHW/MCH programme guided by the socio-ecological framework to transform CHW programmes. The framework can help to address the barriers and scale up the facilitators to ensuring MCH equity and a resilient community health system in SSA.

Utilization of Skilled Birth Attendance among Mothers Who Gave Birth in the Last 12 Months in Kembata Tembaro Zone

BACKGROUND

Skilled delivery is considered the single most important strategy in preventing maternal and neonatal morbidity and mortality. It ensures safe birth, reduces actual and potential complications, and increases the survival of most mothers and newborns.

OBJECTIVE

To identify determinants of the utilization of skilled birth attendance among women who gave birth in the last 12 months in the Kembata Tembaro zone, Southern Ethiopia, 2020.

METHODS

A community-based cross-sectional study was employed from 1 April 2020 to 30 April 2020 among women who gave birth in the last 12 months in the Kembata Tembaro zone. Six hundred twenty-four mothers were recruited for the study as eligible participants. Multistage stratified sampling was used to select three districts and one town administrative unit of the study area. The data were collected and verified for their completeness, followed by editing and coding. Multivariate analysis was performed using the backward LR method to identify factors independently associated with the dependent variable. Statistical significance was declared at a p value of less than 0.05, and the strength of statistical association was measured by adjusted odds ratio and 95% confidence interval.

RESULT

Of 624 study subjects sampled, 607 provided information with a response rate of 97.3%. In this study, 309 (50.9%) women had their last birth at health facilities attended by skilled birth attendants. Place of residence (AOR (95% CI) = 0.33 (0.22,0.58)); age at interview (AOR (95% CI = 3.41 (1.57,5.45)); maternal education (AOR (95% CI) = 1.50 (1.34, 4.19)); history of still birth (AOR (95% CI) = 3.85 (2.14,6.91)); maternal occupation (AOR (95% CI) = 3.35 (1.79,6.27)); husband occupation (AOR (95% CI) = 2.69 (1.70,7.09)); ANC visit (AOR (95% CI) = 4.62 (3.12,7.32)); knowledge of obstetric complications (AOR (95% CI) = 3.10 (1.37,5.21)); and final decision-making about place of delivery (AOR (95% CI) = 3.64 (1.70,7.99)) were significantly associated with the use of skilled birth attendance.

CONCLUSION

In this study, nearly half of the mothers used skilled birth attendance. Place of residence, age at interview, maternal education, history of still birth, maternal occupation, husband occupation, antenatal visit, knowledge about obstetric complications, and final decision-maker about place of delivery were determinants of the use of skilled attendance delivery.

An innovative intervention to improve respectful maternity care in three Districts in Ethiopia

BACKGROUND

Mistreatment of women during facility-based childbirth is a major violation of human rights and often deters women from attending skilled birth. In Ethiopia, mistreatment occurs in up to 49.4% of mothers giving birth in health facilities. This study describes the development, implementation and results of interventions to improve respectful maternity care. As part of a national initiative to reduce maternal and perinatal mortality in Ethiopia, we developed respectful maternity care training module with three core components: testimonial videos developed from key themes identified by staff as experiences of mothers, skills-building sessions on communication and onsite coaching. Respectful maternity care training was conducted in February 2017 in three districts within three regions.

METHODS

Facility level solutions applied to enhance the experience of care were documented. Safe Childbirth Checklist data measuring privacy and birth companion offered during labor and childbirth were collected over 27 months from 17 health centers and three hospitals. Interrupted time series and regression analysis were conducted to assess significance of improvement using secondary routinely collected programmatic data.

RESULTS

Significant improvement in the percentage of births with two elements of respectful maternal care-privacy and birth companionship offered- was noted in one district (with short and long-term regression coefficient of 18 and 27% respectively), while in the other two districts, results were mixed. The short-term regression coefficient in one of the districts was 26% which was not sustained in the long-term while in the other district the long-term coefficient was 77%. Testimonial videos helped providers to see their care from their clients' perspectives, while quality improvement training and coaching helped them reflect on potential root causes for this type of treatment and develop effective solutions. This includes organizing tour to the birthing ward and allowing cultural celebrations.

CONCLUSION

This study demonstrated effective way of improving respectful maternity care. Use of a multipronged approach, where the respectful maternity care intervention was embedded in quality improvement approach helped in enhancing respectful maternity care in a comprehensive manner.

Contributing barriers to loss to follow up from antenatal care services in villages around Addis Ababa: a qualitative study

Background

Problems during pregnancy, childbirth and postpartum are the major contributors to maternal and perinatal morbidity and mortality. Focused antenatal care is an intervention set to provide basic services for pregnant women, to reduce morbidity and mortality related to pregnancy. In Ethiopia, there is a significant loss to follow up from antenatal care services between the first and fourth visits. The aim of this study is to explore the potential contributing barriers to loss to follow up of pregnant women from antenatal care services in villages around Addis Ababa, the capital city of the country.

Methods

A qualitative research method was used, where 20 in-depth interviews (zonal, woreda and health center managers, midwives and health extension workers were the participants) and three focus group discussions (mothers who were lost to follow up, mothers who completed four sessions of antenatal care visits, and community volunteers were the participants) were conducted. A qualitative data analysis software, ATLAS.ti 8, was applied.

Results

Inability to deliver essential antenatal care services which occurs primarily due to shortage of the required medical equipment, drugs, and other supplies is a major barrier for sustainable attendance of antenatal care services followed by poor care, respect, and receptiveness of service providers. Lack and cost of transport as well as partners’ approval and support were also claimed to be part of the major barriers. Community culture and pervious maternal experiences as well as maternal sociodemographic factors like maternal age at time of pregnancy and educational status of mothers were also reported as barriers to seeking and completion of antenatal care services.

Conclusions

Both demand and supply side barriers play a significant role in the loss to follow up from antenatal care services. Availing essential antenatal care services, closer to the community by improving the infrastructure, health workforce and supply chain system is recommended.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12905-021-01290-9.

Examining Healthcare Workers' Perspectives Concerning Medical Equipment Availability in Three Ethiopian Hospitals: A Qualitative Pilot Study

Background

Hospitals in the United States often have an abundance of unused medical supplies and equipment while many developing countries are in considerable need of these resources. Many nongovernmental organizations (NGOs) have donated medical equipment to health centers in low-resource settings to rectify this issue; however, studies show many of these donations are not usable by the facilities that receive them. To better serve the partner hospitals of our NGO, Oasis Medical Relief, we investigated the perspectives and insights of Ethiopian healthcare workers (HCWs) on the medical equipment distribution paradigm of the country.

Methodology

Qualitative analysis including semi-structured, open-ended interviews was conducted. Semi-structured interviews (n = six) were conducted with HCWs (four physicians and two hospital administrators) working in hospitals in Addis Ababa and Southern Nations, Nationalities, and Peoples’ Region (SNNPR) of Ethiopia. Interviews were recorded and transcribed. Categorical content analysis was utilized to develop themes. The topical areas addressed by our questions include populations served, prevalence of diseases, laws, and strategies guiding medical equipment distribution, funding and budget for medical equipment, etc.

Results

Three themes related to perspectives and insights of HCWs on the current medical equipment distribution paradigm in Ethiopia interviewed include: (1) state of healthcare concerns, (2) medical equipment scarcity, and (3) policy shaping medical distribution paradigm.

Conclusions

Pre-donation assessments utilized to understand equipment needs are recognized by the World Health Organization to more effectively address medical equipment/supply. However, to further strengthen such efforts, qualitative interviews with HCWs are a tool that can be utilized to better understand the intricacies of Ethiopia’s complex medical distribution paradigm. This can potentially lead to more effective partnerships between NGOs and their partner hospitals. Furthermore, increasing decentralized methods of procuring medical equipment should be further explored to mitigate issues with national distribution of medical supplies.

Is patient navigation a solution to the problem of "leaving no one behind"? A scoping review of evidence from low-income countries

Patient navigation interventions, which are designed to enable patients excluded from health systems to overcome the barriers they face in accessing care, have multiplied in high-income countries since the 1990s. However, in low-income countries (LICs), indigents are generally excluded from health policies despite the international paradigm of universal health coverage (UHC). Fee exemption interventions have demonstrated their limits and it is now necessary to act on other dimensions of access to healthcare. However, there is a lack of knowledge about the interventions implemented in LICs to support the indigents throughout their care pathway. The aim of this paper is to synthesize what is known about patient navigation interventions to facilitate access to modern health systems for vulnerable populations in LICs. We therefore conducted a scoping review to identify all patient navigation interventions in LICs. We found 60 articles employing a total of 48 interventions. Most of these interventions targeted traditional beneficiaries such as people living with HIV, pregnant women and children. We utilized the framework developed by Levesque et al. (Patient-centred access to health care: conceptualising access at the interface of health systems and populations. Int J Equity Health 2013;12:18) to analyse the interventions. All acted on the ability to perceive, 34 interventions on the ability to reach, 30 on the ability to engage, 8 on the ability to pay and 6 on the ability to seek. Evaluations of these interventions were encouraging, as they often appeared to lead to improved health indicators and service utilization rates and reduced attrition in care. However, no intervention specifically targeted indigents and very few evaluations differentiated the impact of the intervention on the poorest populations. It is therefore necessary to test navigation interventions to enable those who are worst off to overcome the barriers they face. It is a major ethical issue that health policies leave no one behind and that UHC does not benefit everyone except the poorest.

Understanding the importance of non-material factors in retaining community health workers in low-income settings: a qualitative case-study in Ethiopia

OBJECTIVES

The motivation and retention of community health workers (CHWs) is a challenge and inadequately addressed in research and policy. We sought to identify factors influencing the retention of CHWs in Ethiopia and ways to avert their exit.

DESIGN

A qualitative study was undertaken using in-depth interviews with the study participants. Interviews were audio-recorded, and then simultaneously translated into English and transcribed for analysis. Data were analysed in NVivo 12 using an iterative inductive-deductive approach.

SETTING

The study was conducted in two districts each in the Tigray and Southern Nations, Nationalities and People's Republic (SNNPR) regions in Ethiopia. Respondents were located in a mix of rural and urban settings.

PARTICIPANTS

Leavers of health extension worker (HEW) positions (n=20), active HEWs (n=16) and key informants (n=11) in the form of policymakers were interviewed.

RESULTS

We identified several extrinsic and intrinsic motivational factors affecting the retention and labour market choices of HEWs. While financial incentives in the form of salaries and material incentives in the form of improvements to health facility infrastructure, provision of childcare were reported to be important, non-material factors like HEWs' self-image, acceptance and validation by the community and their supervisors were found to be critical. A reduction or loss of these non-material factors proved to be the catalyst for many HEWs to leave their jobs.

CONCLUSION

Our study contributes new empirical evidence to the global debate on factors influencing the motivation and retention of CHWs, by being the first to include job leavers in the analysis. Our findings suggest that policy interventions that appeal to the social needs of CHWs can prove to be more acceptable and potentially cost-effective in improving their retention in the long run. This is important for government policymakers in resource constrained settings like Ethiopia that rely heavily on lay workers for primary healthcare delivery.

Health interventions among mobile pastoralists: a systematic review to guide health service design

OBJECTIVE

Mobile pastoralists are one of the last populations to be reached by health services and are frequently missed by health campaigns. Since health interventions among pastoralists have been staged across a range of disciplines but have not yet been systematically characterised, we set out to fill this gap.

METHODS

We conducted a systematic search in PubMed/MEDLINE, Scopus, Embase, CINAL, Web of Science, WHO Catalog, AGRICOLA, CABI, ScIELO, Google Scholar and grey literature repositories to identify records that described health interventions, facilitators and barriers to intervention success, and factors influencing healthcare utilisation among mobile pastoralists. No date restrictions were applied. Due to the heterogeneity of reports captured in this review, data were primarily synthesised through narrative analysis. Descriptive statistical analysis was performed for data elements presented by a majority of records.

RESULTS

Our search yielded 4884 non-duplicate records, of which 140 eligible reports were included in analysis. 89.3% of reports presented data from sub-Saharan Africa, predominantly in East Africa (e.g. Ethiopia, 30.0%; Kenya, 17.1%). Only 24.3% of reports described an interventional study, while the remaining 75.7% described secondary data of interest on healthcare utilisation. Only two randomised controlled trials were present in our analysis, and only five reports presented data on cost. The most common facilitators of intervention success were cultural sensitivity (n = 16), community engagement (n = 12) and service mobility (n = 11).

CONCLUSION

Without adaptations to account for mobile pastoralists' unique subsistence patterns and cultural context, formal health services leave pastoralists behind. Research gaps, including neglect of certain geographic regions, lack of both interventional studies and diversity of study design, and limited data on economic feasibility of interventions must be addressed to inform the design of health services capable of reaching mobile pastoralists. Pastoralist-specific delivery strategies, such as combinations of mobile and 'temporary fixed' services informed by transhumance patterns, culturally acceptable waiting homes, community-directed interventions and combined joint human-animal One Health design as well as the bundling of other health services, have shown initial promise upon which future work should build.

Health services uptake among nomadic pastoralist populations in Africa: A systematic review of the literature

The estimated 50 million nomadic pastoralists in Africa are among the most "hard-to-reach" populations for health-service delivery. While data are limited, some studies have identified these communities as potential disease reservoirs relevant to neglected tropical disease programs, particularly those slated for elimination and eradication. Although previous literature has emphasized the role of these populations' mobility, the full range of factors influencing health service utilization has not been examined systematically. We systematically reviewed empirical literature on health services uptake among African nomadic pastoralists from seven online journal databases. Papers meeting inclusion criteria were reviewed using STROBE- and PRISMA-derived guidelines. Study characteristics were summarized quantitatively, and 10 key themes were identified through inductive qualitative coding. One-hundred two papers published between 1974-2019 presenting data from 16 African countries met our inclusion criteria. Among the indicators of study-reporting quality, limitations (37%) and data analysis were most frequently omitted (18%). We identified supply- and demand-side influences on health services uptake that related to geographic access (79%); service quality (90%); disease-specific knowledge and awareness of health services (59%); patient costs (35%); contextual tailoring of interventions (75%); social structure and gender (50%); subjects' beliefs, behaviors, and attitudes (43%); political will (14%); social, political, and armed conflict (30%); and community agency (10%). A range of context-specific factors beyond distance to facilities or population mobility affects health service uptake. Approaches tailored to the nomadic pastoralist lifeway, e.g., that integrated human and veterinary health service delivery (a.k.a., "One Health") and initiatives that engaged communities in program design to address social structures were especially promising. Better causal theorization, transdisciplinary and participatory research methods, clearer operational definitions and improved measurement of nomadic pastoralism, and key factors influencing uptake, will improve our understanding of how to increase accessibility, acceptability, quality and equity of health services to nomadic pastoralist populations.

Factors influencing women's access to the maternity waiting home in rural Southwest Ethiopia: a qualitative exploration

Background

Maternity Waiting Homes (MWHs) have been advocated to improve the utilization of skilled birth attendants. Nevertheless, delivery attended by skilled personnel is low in Ethiopia and may indicate that the utilization of MWH is also low. The aim of this study is to explore the factors influencing women’s access to the MWHs in rural Southwest Ethiopia.

Methods

Qualitative data were collected through focus group discussions with MWHs users and in-depth interviews with MWHs non-users, health extension workers and the clinicians. Four focus group discussions and 18 in-depth interviews were conducted between May 1 and June 1, 2017. Furthermore, observations were made to assess the availability of basic facilities at selected MWHs. Data were thematically analyzed using NVivo version 7. The concept of access defined by Thiede et al was applied to guide the analysis.

Results

Women had interest on MWHs and are aware of the existence of MWHs in their immediate vicinity. Health information disseminations and referral linkages by frontline health workers enabled women to timely access the MWHs. However, Women didn’t understand the aims and benefits of MWHs. At the facility level, there were attempts to improve the acceptability of MWHs by allowing women to choose their delivery positions. But, participants claimed lack of privacy and presence of disrespectful care. Physical barriers (long distance, unavailability of transport options & unfavorable roads) were considered as potential problems for women residing in remote areas. MWH users mentioned absences of sufficient basic facilities, poor quality and varieties of food. Because of insufficient facilities, the cost of living was high for most users. The communities try to overcome the indirect costs through contributions in-kind and in-cash.

Conclusions

The factors influencing women’s access to the MWHs were structural and individual and resonate with Thiede et al. dimensions of access. A better understanding of which factors are most influential in preventing women’s access to the MWHs in rural Southwest Ethiopia is needed to appropriately target interventions.

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

Background

Despite the pro-poor health policies in Ethiopia, the utilization of maternal, neonatal, and child health services remains a challenge for the country. Health equity became central in the post-2015 Sustainable Development Goals globally and is a priority for Ethiopia. The aim of this study was to assess equity in utilization of a range of maternal and child health services by applying absolute and relative equity indices.

Methods

Data on maternal and child health utilization emanated from a baseline survey conducted for a large project ‘Optimizing the Health Extension Program from December 2016 to February 2017 in four regions of Ethiopia. The utilization of four or more antenatal care visits; skilled birth attendance; postnatal care within 2 days after childbirth; immunization with BCG, polio 3, pentavalent 3, measles and full immunization of children aged 12–23 months; and vitamin A supplementation for 6–23 months old children were stratified by wealth quintiles. The socioeconomic status of the household was assessed by household assets and measured by constructing a wealth index using principal component analysis. Equity was assessed by applying two absolute inequity indices (Wealth index [quintile 5- quintile 1] and slope index of inequality) and two relative inequity indices (Wealth index [quintile5: quintile1] and concentration index).

Results

The maternal health services utilization was low and inequitably distributed favoring the better-off women. About 44, 71, and 18% of women from the better-off households had four or more antenatal visits, utilized skilled birth attendance and postnatal care within two days compared to 20, 29, and 8% of women from the poorest households, respectively. Skilled birth attendance was the most inequitably distributed maternal health service. All basic immunizations: BCG, polio 3, pentavalent 3, measles, and full immunization in children aged 12–23 months and vitamin A supplementation were equitably distributed.

Conclusion

Utilization of maternal health services was low, inequitable, and skewed against women from the poorest households. In contrast, preventive child health services were equitably distributed. Efforts to increase utilization and reinforcement of pro-poor and pro-rural strategies for maternal, newborn and immunization services in Ethiopia should be strengthened.

Facilitating equitable community-level access to maternal health services: exploring the experiences of Rwanda's community health workers

BACKGROUND

In Rwanda, community health workers (CHWs) are an integral part of the health system. For maternal health, CHWs are involved in linking members of the communities in which they live to the formal health care system to address preventative, routine, and acute maternal care needs. Drawing on the findings from in-depth interviews with maternal health CHWs and observational insights in ten Rwandan districts, we identify specific strategies CHWs employ to provide equitable maternal care while operating in a low resource setting.

METHODS

Using case study methodology approach, we conducted interviews with 22 maternal health CHWs to understand the nature of their roles in facilitating equitable access to maternal care in Rwanda at the community level. Interviews were conducted in five Rwandan districts. Participants shared their experiences of and perceptions on promoting equitable access to maternal health service in their communities.

RESULTS

Four key themes emerged during the analytic process that characterize the contexts and strategic ways in which maternal health CHWs facilitate equitable access to maternal care in an environment of resource scarcity. They are: 1) community building; 2) physical landscapes, which serve as barriers or facilitators both to women's care access and CHWs' equitable service provision; 3) the post-crisis socio-political environment in Rwanda, which highlights resilience and the need to promote maternal health subsequent to the genocide of 1994; and, 4) the strategies used by CHWs to circumvent the constraints of a resource-poor setting and provide equitable maternal health services at the community level.

CONCLUSION

Rwanda's maternal CHWs are heavily responsible for promoting equitable access to maternal health services. Consequently, they may be required to use their own resources for their practice, which could jeopardize their own socio-economic welfare and capacity to meet the demands of their families. Considering the unpaid and untrained nature of this position, we highlight the factors that threaten the sustainability of CHWs' role to facilitate equitable access to maternal care. These threats introduce turbulence into what is a relatively successful community-level health care initiative.

Kangaroo Mother Care implementation research to develop models for accelerating scale-up in India and Ethiopia: study protocol for an adequacy evaluation

INTRODUCTION

Kangaroo Mother Care (KMC) is the practice of early, continuous and prolonged skin-to-skin contact between the mother and the baby with exclusive breastfeeding. Despite clear evidence of impact in improving survival and health outcomes among low birth weight infants, KMC coverage has remained low and implementation has been limited. Consequently, only a small fraction of newborns that could benefit from KMC receive it.

METHODS AND ANALYSIS

This implementation research project aims to develop and evaluate district-level models for scaling up KMC in India and Ethiopia that can achieve high population coverage. The project includes formative research to identify barriers and contextual factors that affect implementation and utilisation of KMC and design scalable models to deliver KMC across the facility-community continuum. This will be followed by implementation and evaluation of these models in routine care settings, in an iterative fashion, with the aim of reaching a successful model for wider district, state and national-level scale-up. Implementation actions would happen at three levels: 'pre-KMC facility'-to maximise the number of newborns getting to a facility that provides KMC; 'KMC facility'-for initiation and maintenance of KMC; and 'post-KMC facility'-for continuation of KMC at home. Stable infants with birth weight<2000 g and born in the catchment population of the study KMC facilities would form the eligible population. The primary outcome will be coverage of KMC in the preceding 24 hours and will be measured at discharge from the KMC facility and 7 days after hospital discharge.

ETHICS AND DISSEMINATION

Ethics approval was obtained in all the project sites, and centrally by the Research Ethics Review Committee at the WHO. Results of the project will be submitted to a peer-reviewed journal for publication, in addition to national and global level dissemination.

STUDY STATUS

WHO approved protocol: V.4-12 May 2016-Protocol ID: ERC 2716. Study implementation beginning: April 2017. Study end: expected March 2019.

TRIAL REGISTRATION NUMBER

Community Empowerment Laboratory, Uttar Pradesh, India (ISRCTN12286667); St John's National Academy of Health Sciences, Bangalore, India and Karnataka Health Promotion Trust, Bangalore, India (CTRI/2017/07/008988); Society for Applied Studies, Delhi (NCT03098069); Oromia, Ethiopia (NCT03419416); Amhara, SNNPR and Tigray, Ethiopia (NCT03506698).

The impact of the Ethiopian health extension program and health development army on maternal mortality: A synthetic control approach

The Ethiopian government has implemented nationwide strategies to improve access to basic health services and enhance health outcomes. The Health Extension Program (HEP) launched in 2003, expanded basic health infrastructure and local human resources. In 2011, the government introduced the Health Development Army (HDA). HDA is a women-centered community movement inspired by military structures and discipline. Its special objective is to improve maternal health outcomes. This paper uses a synthetic control approach to assess the effects of HEP and HDA on maternal mortality ratios (MMR). The MMR data are from the Global Burden of Diseases (GBD) database. A pool of 42 Sub-Saharan African countries, covering the period 1990 to 2016, is used to construct a synthetic comparator which displays a mortality trajectory similar to Ethiopia prior to the interventions. On average, since 2004, maternal mortality in the control countries exhibits a moderate downward trend. In Ethiopia, the downward trend is considerably steeper as compared to its synthetic control. By 2016, maternal mortality in Ethiopia was lower by 171 (p-value 0.048) maternal deaths per 100,000 live births as compared to its synthetic control. Between 2003 and 2016, Ethiopia's maternal mortality ratio declined from 728 to 357. These estimates suggest that a substantial proportion of this decline may be attributed to HEP/HDA. The Ethiopian experience of enhancing nation-wide access to and use of maternal health services in a short time-span is remarkable. Whether such a model may be transplanted is an open question.

Contribution of women's development army to maternal and child health in Ethiopia: a systematic review of evidence

OBJECTIVE

The aim of this review was to identify, appraise and synthesise studies that reported on the contribution of women's development army (WDA) to maternal and child health development.

SETTING

Studies conducted in Ethiopia 2010 onwards and published in English were considered.

DATA SOURCES

Evidence were searched in MEDLINE, CINAHL and EBSCOhost from 25 March to 10 April 2018.

ELIGIBILITY CRITERIA

Both quantitative and qualitative studies assessing the contribution of WDA to maternal and child health were considered.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers have extracted data using pre-planned data extraction tool separately for each study design. Findings were synthesised using tables and narrative summary.

OUTCOME

Maternal and child health services; maternal and child mortality.

RESULTS

Nine studies met the inclusion criteria and were used for synthesis. The results revealed that participation and membership in women's development teams (WDTs) have a positive effect on minimising maternal death and improving child immunisation service use. Skilled delivery and antenatal care service use were higher in WDTs located within a radius of 2 km from health facilities. Women's development teams were also the main sources of information for mothers to prepare themselves for birth and related complications. Moreover, well-established groups have strengthened the linkage of the health facility to the community so that delays in maternal health service use were minimised; health extension workers could effectively refer women to a health facility for birth and utilisation of skilled birth service was improved.

CONCLUSION

Voluntary health service intervention in Ethiopia has improved maternal and child health services' outcome. A decrease in maternal deaths, increase in antenatal and delivery service use and improved child immunisation service uptake are attributable to this intervention. The linkage between community members and the primary healthcare system served as an effective and efficient mechanism to share information.

"We Prefer the Friendly Approach and Not the Facility": On the Value of Qualitative Research in Ethiopia

Background

Quantitative research is useful for answering 'how many' or 'how much' questions, while qualitative research helps answer 'why' and 'how' questions. Most research about health extension workers (HEWs) has been quantitative and few studies examine the experiences of HEWs themselves. This qualitative study draws attention to the gendered dynamics of human resources for health at the community level.

Methods

Focus Group Discussions (FGDs) with 14 HEWs (two FGDs in Afar Region and two in Southern Nations Nationality and Peoples Region), and interviews with 45 HEWs from Afar Region, SNNPR and Adwa (Tigray Region) were conducted to identify how gender issues affected their well-being. Questions were designed to explore personal safety, stress, autonomy, self-esteem, family, other social relationships, as we wanted to analyze the extent to which these gendered issues affected HEWs in their day-to-day work.

Results

By employing female HEWs, the Health Extension Program (HEP) has seen substantial gains in 'practical' gender needs by improving women's access to, and utilization of maternal and child health services. Although the HEP has the potential to be gender transformative by providing employment for HEWs, there is limited evidence that it 'strategically' advances women's position. Many HEWs had heavy workloads, received low pay relative to other public sector jobs and lacked opportunity to transfer or upgrade their skills and advance within the health workforce hierarchy.

Conclusion

Qualitative research can provide complex descriptions of the social world to better understand what people such as HEWs say and the meanings they give, thus providing explanations for some health problems outside disciplinary boundaries.

Community health extension program of Ethiopia, 2003-2018: successes and challenges toward universal coverage for primary healthcare services

BACKGROUND

Ethiopia has been implementing a community health extension program (HEP) since 2003. We aimed to assess the successes and challenges of the HEP over time, and develop a framework that may assist the implementation of the program toward universal primary healthcare services.

METHODS

We conducted a systematic review and synthesis of the literature on the HEP in Ethiopia between 2003 and 2018. Literature search was accomplished in PubMed, Embase and Google scholar databases. Literature search strategies were developed using medical subject headings (MeSH) and text words related to the aim of the review. We used a three-stage screening process to select the publications. Data extraction was conducted by three reviewers using pre-prepared data extraction form. We conducted an interpretive (not aggregative) synthesis of studies.

FINDINGS

The HEP enabled Ethiopia to achieve significant improvements in maternal and child health, communicable diseases, hygiene and sanitation, knowledge and health care seeking. The HEP has been a learning organization that adapts itself to community demands. The program is also dynamic enough to shift tasks between health centers and community. The community has been a key player in the successful implementation of the HEP. In spite of these successes, the program is currently facing challenges that remain to be addressed. These challenges are related to productivity and efficiency of health extension workers (HEWs); working and living conditions of HEWs; capacity of health posts; and, social determinants of health. These require a systemic approach that involves the wider health system, community, and sectors responsible for social determinants of health. We developed a framework that may assist in the implementation of the HEP.

CONCLUSION

The HEP has enabled Ethiopia to achieve significant improvements. However, several challenges remain to be addressed. The framework can be utilized to improve community health programs toward universal coverage for primary healthcare services.

Gender exploitative and gender transformative aspects of employing Health Extension Workers under Ethiopia's Health Extension Program

OBJECTIVES

To apply a gender lens to Ethiopia's Health Extension Program and the role of Health Extension Workers (HEWs).

METHODS

Interviews with 45 HEWs and four focus group discussions with 14 of the same HEWS from three regions in rural Ethiopia: Afar Region; Tigray Region (Adwa Woreda); and two locations in Southern Nations, Nationalities and People's Region (Aleta Wondo Woreda and Kafa Zone). Two focus group discussions were conducted in Afar Region with 17 Women Extension Workers employed by Afar Pastoralist Development Association.

RESULTS

Using the Gender Equality Continuum as a gender analysis tool, we found that Ethiopia's Health Extension Program is gender aware by directly linking improved health outcomes for women and their empowerment. However, for HEWs who inhabit a gendered space and place from home to district health centres, there can be unexpected consequences that accommodate existing gender inequalities, are blind to them and perhaps even generate new forms of exploitation.

CONCLUSIONS

The Health Extension Program could have more transformative outcomes for HEWs and also for communities if changing gender norms was given more attention and constraints to gender equality were reduced. Community Health Worker (CHW) programs should focus on better understanding on the role of gender for CHWs across health systems.

A discrete choice experiment to determine facility-based delivery services desired by women and men in rural Ethiopia

OBJECTIVES

Despite global efforts to increase facility-based delivery (FBD), 90% of women in rural Ethiopia deliver at home without a skilled birth attendant. Men have an important role in increasing FBD due to their decision-making power, but this is largely unexplored. This study aimed to determine the FBD care attributes preferred by women and men, and whether poverty or household decision-making are associated with choice to deliver in a facility.

SETTING AND PARTICIPANTS

We conducted a cross-sectional discrete choice experiment in 109 randomly selected households in rural Ethiopia in September-October 2015. We interviewed women who were pregnant or who had a child <2 years old and their male partners.

RESULTS

Both women and men preferred health facilities where medications and supplies were available (OR=3.08; 95% CI 2.03 to 4.67 and OR=2.68; 95% CI 1.79 to 4.02, respectively), a support person was allowed in the delivery room (OR=1.69; 95% CI 1.37 to 2.07 and OR=1.74; 95% CI 1.42 to 2.14, respectively) and delivery cost was low (OR=1.15 95% CI 1.12 to 1.18 and OR=1.14; 95% CI 1.11 to 1.17, respectively). Women valued free ambulance service (OR=1.37; 95% CI 1.09 to 1.70), while men favoured nearby facilities (OR=1.09; 95% CI 1.06 to 1.13) with friendly providers (OR=1.30; 95% CI 1.03 to 1.64). Provider preferences were complex. Neither women nor men preferred female doctors to health extension workers (HEW) (OR=0.92; 95% CI 0.59 to 1.42 and OR=0.74; 95% CI 0.47 to 1.14, respectively), male doctors to HEW (OR=1.33; 95% CI 0.89 to 1.99 and OR=0.75; 95% CI 0.50 to 1.12, respectively) or female over male nurses (OR=0.68; 95% CI 0.94 to 1.71 and OR=1.03; 95% CI 0.77 to 2.94, respectively). While both women and men preferred male nurses to HEW (OR=1.86; 95% CI 1.23 to 2.80 and OR=1.95; 95% CI 1.30 to 2.95, respectively), men (OR=1.89; 95% CI 1.29 to 2.78), but not women (OR=1.47; 95% CI 1.00 to 2.13) preferred HEW to female nurses. Both women and men preferred female doctors to male nurses (OR=1.71; 95% CI 1.27 to 2.29 and OR=1.44; 95% CI 1.07 to 1.92, respectively), male doctors to female nurses (OR=1.95; 95% CI 1.44 to 2.62 and OR=1.41; 95% CI 1.05 to 1.90, respectively) and male doctors to male nurses (OR=2.47; 95% CI 1.84 to 3.32 and OR=1.46; 95% CI 1.09 to 1.95, respectively), while only women preferred male doctors to female doctors (OR=1.45; 95% CI 1.09 to 1.93 and OR=1.01; 95% CI 0.76 to 1.35, respectively) and only men preferred female nurses to female doctors (OR=1.34; 95% CI 0.98 to 1.84 and OR=1.39; 95% CI 1.02 to 1.89, respectively). Men were disproportionately involved in making household decisions (X² (1, n=216)=72.18, p<0.001), including decisions to seek healthcare (X² (1, n=216)=55.39, p<0.001), yet men were often unaware of their partners' prenatal care attendance (X² (1, n=215)=82.59, p<0.001).

CONCLUSION

Women's and men's preferences may influence delivery service choices. Considering these choices is one way the Ethiopian government and health facilities may encourage FBD in rural areas.