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Gebremedhin S, Shiferie F, Tsegaye DA, Alemayehu WA, Wondie T, Zeleke S, Alebachew B, Donofrio J, DelPizzo F, Belete K, Biks GA. Perspectives on the Performance of the Ethiopian Vaccine Supply Chain and Logistics System after the Last Mile Delivery Initiative: A Phenomenological Study. Am J Trop Med Hyg 2024; 110:1029-1038. [PMID: 38574549 DOI: 10.4269/ajtmh.23-0622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 12/20/2023] [Indexed: 04/06/2024] Open
Abstract
Uninterrupted availability of vaccines requires a robust vaccine supply chain and logistics system (VSCLS). With special focus on remote and underserved settings, we assessed the reach and bottlenecks of the Ethiopian VSCLS after the initiation of the last mile transition. We explored the perspectives of key stakeholders using a qualitative phenomenological study. More than 300 in-depth interviews and 22 focus group discussions were conducted. The study was sequentially implemented over two phases to understand the bottlenecks at national and regional (Phase I) and lower (Phase II) levels. After the transition, the Ethiopian Pharmaceutical Supply Service started supplying vaccines directly to health facilities, bypassing intermediaries. The transition reduced supply hiccups and enabled the health sector to focus on its core activities. However, in remote areas, achievements were modest, and health facilities have been receiving supplies indirectly through district health offices. By design, health posts collect vaccines from health centers, causing demotivation of health extension workers and frequent closure of health posts. Challenges of the VSCLS include artificial shortage due to ill forecasting and failure to request needs on time, lack of functional refrigerators secondary to scarcity of skilled technicians and spare parts, and absence of dependable backup power at health centers. Vaccine wastages owing to poor forecasts, negligence, and cold chain problems are common. The VSCLS has not yet sustainably embraced digital logistics solutions. The system is overstrained by frequent outbreak responses and introduction of new vaccines. We concluded that the transition has improved the VSCLS, but the reach remains suboptimal in remote areas.
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Affiliation(s)
| | | | - Dawit A Tsegaye
- Project HOPE, Ethiopia Country Office, Addis Ababa, Ethiopia
| | | | - Tamiru Wondie
- Project HOPE, Ethiopia Country Office, Addis Ababa, Ethiopia
| | - Solomon Zeleke
- Project HOPE, Ethiopia Country Office, Addis Ababa, Ethiopia
| | | | - Jen Donofrio
- Bill and Melinda Gates Foundation, Seattle, Washington
| | | | - Kidist Belete
- U.S. Agency for International Development, Ethiopia, Addis Ababa, Ethiopia
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Biks GA, Shiferie F, Tsegaye DA, Asefa W, Alemayehu L, Wondie T, Zelalem M, Lakew Y, Belete K, Gebremedhin S. High prevalence of zero-dose children in underserved and special setting populations in Ethiopia using a generalize estimating equation and concentration index analysis. BMC Public Health 2024; 24:592. [PMID: 38395877 PMCID: PMC10893596 DOI: 10.1186/s12889-024-18077-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 02/12/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND Globally, according to the World Health Organization (WHO) 2023 report, more than 14.3 million children in low- and middle-income countries, primarily in Africa and South-East Asia, are not receiving any vaccinations. Ethiopia is one of the top ten countries contributing to the global number of zero-dose children. OBJECTIVE To estimate the prevalence of zero-dose children and associated factors in underserved populations of Ethiopia. METHODS A cross-sectional vaccine coverage survey was conducted in June 2022. The study participants were mothers of children aged 12-35 months. Data were collected using the CommCare application system and later analysed using Stata version 17. Vaccination coverage was estimated using a weighted analysis approach. A generalized estimating equation model was fitted to determine the predictors of zero-dose children. An adjusted odds ratio (AOR) with 95% confidence interval (CI) and a p-value of 0.05 or less was considered statistically significant. RESULTS The overall prevalence of zero-dose children in the study settings was 33.7% (95% CI: 34.9%, 75.7%). Developing and pastoralist regions, internally displaced peoples, newly formed regions, and conflict-affected areas had the highest prevalence of zero-dose children. Wealth index (poorest [AOR = 2.78; 95% CI: 1.70, 4.53], poorer [AOR = 1.96; 95% CI: 1.02, 3.77]), single marital status [AOR = 2.4; 95% CI: 1.7, 3.3], and maternal age (15-24 years) [AOR = 1.2; 95% CI: 1.1, 1.3] were identified as key determinant factors of zero-dose children in the study settings. Additional factors included fewer than four Antenatal care visits (ANC) [AOR = 1.3; 95% CI: 1.2, 1.4], not receiving Postnatal Care (PNC) services [AOR = 2.1; 95% CI: 1.5, 3.0], unavailability of health facilities within the village [AOR = 3.7; 95% CI: 2.6, 5.4], women-headed household [AOR = 1.3; 95% CI:1.02, 1.7], low gender empowerment [AOR = 1.6; 95% CI: 1.3, 2.1], and medium gender empowerment [AOR = 1.7; 95% CI: 1.2, 2.5]. CONCLUSION In the study settings, the prevalence of zero-dose children is very high. Poor economic status, disempowerment of women, being unmarried, young maternal age, and underutilizing antenatal or post-natal services are the important predictors. Therefore, it is recommended to target tailored integrated and context-specific service delivery approach. Moreover, extend immunization sessions opening hours during the evening/weekend in the city administrations to meet parents' needs.
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Affiliation(s)
| | | | | | | | | | - Tamiru Wondie
- Project HOPE, Ethiopia Country Office, Addis Ababa, Ethiopia
| | - Meseret Zelalem
- Maternal and Child Health, Minister of Health, Addis Ababa, Ethiopia
| | - Yohannes Lakew
- Maternal and Child Health, Minister of Health, Addis Ababa, Ethiopia
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Biks GA, Shiferie F, Tsegaye DA, Asefa W, Alemayehu L, Wondie T, Seboka G, Hayes A, RalphOpara U, Zelalem M, Belete K, Donofrio J, Gebremedhin S. In-depth reasons for the high proportion of zero-dose children in underserved populations of Ethiopia: Results from a qualitative study. Vaccine X 2024; 16:100454. [PMID: 38327767 PMCID: PMC10847948 DOI: 10.1016/j.jvacx.2024.100454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 01/18/2024] [Accepted: 01/30/2024] [Indexed: 02/09/2024] Open
Abstract
Increasing attention is being given to reach children who fail to receive routine vaccinations, commonly designated as zero-dose children. A comprehensive understanding of the supply- and demand-side barriers is essential to inform zero-dose strategies in high-burden countries and achieve global immunization goals. This qualitative study aimed to identify the barriers for reaching zero-dose and under-immunized children and what and explore gender affects access to vaccination services for children in Ethiopia. Data was collected between March-June 2022 using key informant interviews and focus group discussions with participants in underserved settings. The high proportion of zero-dose children was correlated with inadequate information being provided by health workers, irregularities in service provision, suboptimal staff motivation, high staff turnover, closure and inaccessibility of health facilities, lack of functional health posts, service provision limited to selected days or hours, and gender norms viewing females as responsible for childcare. Demand-side barriers included religious beliefs, cultural norms, fear of vaccine side effects, and lack of awareness and sustained interventions. Recommendations to increase vaccination coverage include strengthening health systems such as services integration, human resources capacity building, increasing incentives for health staff, integrating vaccination services, bolstering the EPI budget especially from the government side, and supporting reliable outreach and static immunization services. Additionally, immunization policy should be revised to include gender considerations including male engagement strategies to improve uptake of immunization services.
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Affiliation(s)
| | | | | | | | | | - Tamiru Wondie
- Project HOPE, Ethiopia Country Office, Addis Ababa, Ethiopia
| | - Gobena Seboka
- Project HOPE, Ethiopia Country Office, Addis Ababa, Ethiopia
| | | | | | - Meseret Zelalem
- Maternal and Child Health, Minister of Health, Addis Ababa, Ethiopia
| | - Kidist Belete
- USAID Ethiopia Country Office, Addis Ababa, Ethiopia
| | - Jen Donofrio
- Bill and Melinda Gates Foundation, United States
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Gebremedhin S, Shiferie F, Tsegaye DA, Alemayehu WA, Wondie T, Donofrio J, DelPizzo F, Belete K, Biks GA. Oral and Inactivated Polio Vaccine Coverage and Determinants of Coverage Inequality Among the Most At-Risk Populations in Ethiopia. Am J Trop Med Hyg 2023; 109:1148-1156. [PMID: 37748762 PMCID: PMC10622460 DOI: 10.4269/ajtmh.23-0319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 07/08/2023] [Indexed: 09/27/2023] Open
Abstract
Combining oral (OPV) and inactivated (IPV) poliovirus vaccines prevents importation of poliovirus and emergence of circulating vaccine-derived poliovirus. We measured the coverage with IPV and third dose of OPV (OPV-3) and identified determinants of coverage inequality in the most at-risk populations in Ethiopia. A national survey representing 10 partly overlapping underserved populations-pastoralists, conflict-affected areas, urban slums, hard-to-reach settings, developing regions, newly formed regions, internally displaced people (IDPs), refugees, and districts neighboring international and interregional boundaries-was conducted among children 12 to 35 months old (N = 3,646). Socioeconomic inequality was measured using the concentration index (CIX) and decomposed using a regression-based approach. One-third (95% CI: 31.5-34.0%) of the children received OPV-3 and IPV. The dual coverage was below 50% in developing regions (19.2%), pastoralists (22.0%), IDPs (22.3%), districts neighboring international (24.1%) and interregional (33.3%) boundaries, refugees (27.0%), conflict-affected areas (29.3%), newly formed regions (33.5%), and hard-to-reach areas (38.9%). Conversely, coverage was better in urban slums (78%). Children from poorest households, living in villages that do not have health posts, and having limited health facility access had increased odds of not receiving the vaccines. Low paternal education, dissatisfaction with vaccination service, fear of vaccine side effects, living in female-headed households, having employed and less empowered mothers were also risk factors. IPV-OPV3 coverage favored the rich (CIX = -0.161, P < 0.001), and causes of inequality were: inaccessibility of health facilities (13.3%), dissatisfaction with vaccination service (12.8%), and maternal (4.9%) and paternal (4.9%) illiteracy. Polio vaccination coverage in the most at-risk populations in Ethiopia is suboptimal, threatening the polio eradication initiative.
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Affiliation(s)
| | | | | | | | - Tamiru Wondie
- Project HOPE, Ethiopia Country Office, Addis Ababa, Ethiopia
| | - Jen Donofrio
- Bill & Melinda Gates Foundation, Seattle, Washington
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Shiferie F, Gebremedhin S, Andargie G, Tsegaye DA, Alemayehu WA, Mekuria LA, Wondie T, Fenta TG. Vaccination dropout and wealth related inequality among children aged 12-35 months in remote and underserved settings of Ethiopia: a cross-sectional evaluation survey. Front Pediatr 2023; 11:1280746. [PMID: 37941975 PMCID: PMC10628708 DOI: 10.3389/fped.2023.1280746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 10/11/2023] [Indexed: 11/10/2023] Open
Abstract
Background Vaccination is one of the most cost-effective public health interventions that prevents millions of deaths. Although immunization coverage is increasing globally, many children in low- and middle-income countries drop out of the vaccination continuum. This study aimed at determining vaccination dropout rates and predictors in children aged 12-35 months in remote and underserved areas of Ethiopia. Methods This study was part of a cross-sectional evaluation survey that was conducted in 2022 in Ethiopia. The study settings include pastoralist, developing & newly established regions, conflict affected areas, urban slums, internally displaced populations and refugees. A sample of 3,646 children aged 12-35 months were selected using a cluster sampling approach. Vaccination dropout was estimated as the proportion of children who did not get the subsequent vaccine among those who received the first vaccine. A generalized estimating equation was used to assess determinants of the dropout rate and findings were presented using an adjusted odds ratio with 95% confidence interval. Concentration curve and index were used to estimate wealth related inequality of vaccination dropout. Results A total of 3,646 caregivers of children participated in the study with a response rate of 97.7%. The BCG to Penta-3 (52.5%), BCG to MCV-2 (57.4%), and Penta-1 to Penta-3 (43.9%) dropouts were all high. The highest Penta-1 to Penta-3 dropout rate was found in developing regions (60.1%) and the lowest was in urban slums (11.2%). Caregivers who were working outside their homes [AOR (95% CI) = 3.67 (1.24-10.86)], who had no postnatal care follow-up visits [AOR (95%CI) = 1.66 (1.15-2.39)], who did not receive a service from a skilled birth attendant [AOR (95%CI) = 1.64 (1.21-2.27)], who were older than 45 years [AOR (95% CI) = 12.49 (3.87-40.33)], and who were less gender empowered [AOR (95%CI) = 1.63 (1.24-2.15)] had increased odds of Penta-1 to Penta-3 dropout. The odds of dropout for children from poor caregivers was nearly two times higher compared to their wealthy counterparts [AOR (95%CI) = 1.87 (1.38-2.52)]. Conclusion Vaccination dropout estimates were high among children residing in remote and underserved settings. Poor wealth quintile, advanced maternal age, low women empowerment, and limited utilization of maternity care services contributed to vaccination dropout.
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Affiliation(s)
- Fisseha Shiferie
- Project HOPE Ethiopia Country Office, Addis Ababa, Ethiopia
- School of Pharmacy, Addis Ababa University, Addis Ababa, Ethiopia
| | | | | | | | | | | | - Tamiru Wondie
- Project HOPE Ethiopia Country Office, Addis Ababa, Ethiopia
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Abtew S, Negatou M, Wondie T, Tadesse Y, Alemayehu WA, Tsegaye DA, Mulaw M, Muluneh D, Collison D, Mdluli EA, Mekuria LA. Poor Adherence to the Integrated Community Case Management of Newborn and Child Illness Protocol in Rural Ethiopia. Am J Trop Med Hyg 2022; 107:1337-1344. [PMID: 36316002 PMCID: PMC9768262 DOI: 10.4269/ajtmh.21-1018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Accepted: 06/27/2022] [Indexed: 12/30/2022] Open
Abstract
Ethiopia has adopted the Integrated Community Case Management of Newborn and Child Illness (iCMNCI) strategy to expand access to neonatal and child health services. This study assessed compliance with the iCMNCI case management protocol at the primary care settings. A descriptive cross-sectional assessment was conducted in eight districts of Benishangul-Gumuz Region from April to December 2019, and 1,217 sick children aged 2 to 59 months and 43 sick young infants aged 0 to 2 months who sought clinical consultation at the 236 health posts were selected purposively. Trained supervisors reviewed the medical records of two most recent cases from each illness category to quantify the extent to which health workers correctly assessed, classified, treated, and followed up cases per the iCMNCI guidelines. A total of 32,981 children sought clinical consultation of whom 31,830 (96.5%) were aged 2 to 59 months, and 1,151 (3.5%) were young infants aged 0 to 2 months. Of the 1,217 selected children, 426 (35%) had pneumonia, 287 (23.6%) malaria, 501 (41.2%) diarrhea, and 3 (0.2%) had malnutrition. Nearly two-thirds 306 (72%) of pneumonia cases were correctly classified as having had the disease and 297 (70%) were correctly treated for pneumonia; 213 (74%) were correctly classified as having had malaria and 210 (73%) were correctly treated for malaria; and 393 (78%) were correctly classified as having had diarrhea and 297 (59%) were correctly treated for diarrhea. Generally, the current practices of child illness assessment, classification, and treatment have deviated from iCMNCI guidelines. Future interventions should support frontline health workers to comply strictly with case management protocols through training, mentorship, and supervision.
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Affiliation(s)
- Solomon Abtew
- Project HOPE, Assosa, Ethiopia;,Address correspondence to Solomon Abtew, Project HOPE, Assosa, P.O. Box 45 Addis Ababa Ethiopia, Ethiopia. E-mail:
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Germossa GN, Wondie T, Gerbaba M, Mohammed E, Alemayehu WA, Tekeste A, Mdluli EA, Kenyon T, Collison D, Tsegaye S, Abera Y, Tadesse D, Daga WB, Shaweno T, Abrar M, Ibrahim A, Belete M, Esmael S, Tadesse D, Alemayehu YK, Medhin G, Fayssa MD. Availability of comprehensive emergency obstetric and neonatal care in developing regions in Ethiopia: lessons learned from the USAID transform health activity. BMC Health Serv Res 2022; 22:1307. [PMID: 36324131 PMCID: PMC9628556 DOI: 10.1186/s12913-022-08712-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 10/20/2022] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND In collaboration with its partners, the Ethiopian government has been implementing standard Emergency Obstetric and Neonatal Care Services (CEmONC) since 2010. However, limited studies documented the lessons learned from such programs on the availability of CEmONC signal functions. This study investigated the availability of CEmONC signal functions and described lessons learned from Transform Health support in Developing Regional State in Ethiopia. METHOD At baseline, we conducted a cross-sectional study covering 15 public hospitals in four developing regions of Ethiopia (Somali, Afar, Beneshangul Gumz, and Gambella). Then, clinical mentorship was introduced in ten selected hospitals. This was followed by reviewing the clinical mentorship program report implemented in all regions. We used the tool adapted from an Averting Maternal Death and Disability tools to collect data through face-to-face interviews. We also reviewed maternal and neonatal records. We then descriptively analyzed the data and presented the findings using text, tables, and graphs. RESULT At baseline, six out of the 15 hospitals performed all the nine CEmONC signal functions, and one-third of the signal functions were performed in all hospitals. Cesarean Section service was available in eleven hospitals, while blood transfusion was available in ten hospitals. The least performed signal functions were blood transfusion, Cesarean Section, manual removal of placenta, removal of retained product of conceptus, and parenteral anticonvulsants. After implementing the clinical mentorship program, all CEmONC signal functions were available in all hospitals selected for the mentorship program except for Abala Hospital; the number of Cesarean Sections increased by 7.25% at the last quarter of 2021compared to the third quarter of 20,219; and the number of women referred for blood transfusions and further management of obstetric complications decreased by 96.67% at the last quarter of 2021 compared to the third quarter of 20,219. However, the number of women with post-cesarean Section surgical site infection, obstetric complications, facility maternal deaths, neonatal deaths, and stillbirths have not been changed. CONCLUSION The availability of CEmONC signal functions in the supported hospitals did not change the occurrence of maternal death and stillbirth. This indicates the need for investigating underlying and proximal factors that contributed to maternal death and stillbirth in the Developing Regional State of Ethiopia. In addition, there is also the need to assess the quality of the CEmONC services in the supported hospitals, institutionalize reviews, surveillance, and response mechanism for maternal and perinatal or neonatal deaths and near misses.
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Affiliation(s)
- Gugsa Nemera Germossa
- grid.411903.e0000 0001 2034 9160School of Nursing, Jimma University, Jimma, Ethiopia
| | - Tamiru Wondie
- Project HOPE, USAID Transform Health in Developing Regions, Addis Ababa, Ethiopia
| | - Mulusew Gerbaba
- grid.411903.e0000 0001 2034 9160Department of Epidemiology, Jimma University, Jimma, Ethiopia
| | - Eyob Mohammed
- Ethiopian Society of Obstetrics and Gynecology, Addis Ababa, Ethiopia
| | | | - Asayehegn Tekeste
- Project HOPE, USAID Transform Health in Developing Regions, Addis Ababa, Ethiopia
| | - Eden Ahmed Mdluli
- grid.420171.10000 0001 1013 6487Project HOPE, Washington DC, Washington USA
| | - Thomas Kenyon
- grid.420171.10000 0001 1013 6487Project HOPE, Washington DC, Washington USA
| | - Deborah Collison
- grid.420171.10000 0001 1013 6487Project HOPE, Washington DC, Washington USA
| | - Sentayehu Tsegaye
- USAID Transform Health in Developing Regions, Amref Health Africa, Addis Ababa, Ethiopia
| | - Yared Abera
- USAID Transform Health in Developing Regions, Amref Health Africa, Addis Ababa, Ethiopia
| | - Derebe Tadesse
- USAID Transform Health in Developing Regions, Amref Health Africa, Addis Ababa, Ethiopia
| | - Wakgari Binu Daga
- grid.494633.f0000 0004 4901 9060School of Public Health, Wolaita Sodo University, Sodo, Ethiopia
| | - Tamrat Shaweno
- grid.508167.dAfrica Centers for Diseases Control and Prevention (Africa CDC), Addis Ababa, Ethiopia
| | - Mohammed Abrar
- Amref Health Africa, Afar Regional Office, Semera, Ethiopia
| | - Ahmed Ibrahim
- AMref Health Africa, Somali Regional Office, Jijiga, Ethiopia
| | - Mebrie Belete
- AMref Health Africa, Gambela Regional Office, Gambela, Ethiopia
| | - Salah Esmael
- Amref Health Africa, Beneshangul Regional Office, Asosa, Ethiopia
| | | | - Yibeltal Kiflie Alemayehu
- MERQ Consultancy PLC, Addis Ababa, Ethiopia ,grid.411903.e0000 0001 2034 9160Department of Health Economics, Management, and Policy, Jimma University, Jimma, Ethiopia
| | - Girmay Medhin
- MERQ Consultancy PLC, Addis Ababa, Ethiopia ,grid.7123.70000 0001 1250 5688Aklilu Lemma Institute of Pathobiology, Addis Ababa University, Addis Ababa, Ethiopia
| | - Mekdes Daba Fayssa
- Ethiopian Society of Obstetrics and Gynecology, Addis Ababa, Ethiopia ,grid.460724.30000 0004 5373 1026St. Paul’s Hospital Millennium Medical College, Addis Ababa, Ethiopia
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