Factors associated with perinatal mortality among public health deliveries in Addis Ababa, Ethiopia, an unmatched case control study

BACKGROUND

perinatal mortality is the sum of still birth (fetal death) and early neonatal death (ENND) i.e. death of live newborn before the age of 7 completed days. Perinatal mortality accounts three fourth of the deaths of the neonatal period and is one of the major challenges for under-five mortality. Therefore this study was conducted to better understand the common and avoidable factors that affect perinatal mortality in Addis Ababa, Ethiopia.

METHODS

An unmatched case control study design using secondary data as a source of information was conducted. Cases were still births or early neonatal deaths and controls were live births and neonates who were discharged alive from the hospital and did not die before the age of 7 days. The study period was from 1st January up to 30th February 2015. Epi-Info version 7.0 and SPSS Version 21 were used for data entry and analysis. Descriptive statistics, frequencies, proportions and diagrams were used to check the distribution of outcome variable and describe the study population. Logistic regression model was used to identify the important factors that are associated with perinatal mortality.

RESULTS

A total of 1113(376 cases and 737 controls) maternal charts were reviewed. The mean age of the mothers for cases and controls were 26.47 ± 4.87 and 26.95 ± 4.68 respectively. Five hundred ninety seven (53.6%) mothers delivered for the first time. Factors that are significantly associated with increased risk of perinatal mortality were birth interval less than 2 years, preterm delivery, anemia, congenital anomaly, previous history of early neonatal death and low birth weight. Use of partograph was also associated with decreased risk of perinatal mortality.

CONCLUSION

From factors that are associated with perinatal mortality, some of them can be prevented with early investigation of pregnant mothers on their antenatal care follow. Appropriate labor follow-up and monitoring with regular use of partograph, immediate newborn care and interventions to delay birth interval also minimize perinatal mortality.

The Effects of a Locally Developed mHealth Intervention on Delivery and Postnatal Care Utilization; A Prospective Controlled Evaluation among Health Centres in Ethiopia

Background

Although there are studies showing that mobile phone solutions can improve health service delivery outcomes in the developed world, there is little empirical evidence that demonstrates the impact of mHealth interventions on key maternal health outcomes in low income settings.

Methods

A non-randomized controlled study was conducted in the Amhara region, Ethiopia in 10 health facilities (5 intervention, 5 control) together serving around 250,000 people. Health workers in the intervention group received an android phone (3 phones per facility) loaded with an application that sends reminders for scheduled visits during antenatal care (ANC), delivery and postnatal care (PNC), and educational messages on dangers signs and common complaints during pregnancy. The intervention was developed at Addis Ababa University in Ethiopia. Primary outcomes were the percentage of women who had at least 4 ANC visits, institutional delivery and PNC visits at the health center after 12 months of implementation of the intervention.

Findings

Overall 933 and 1037 women were included in the cross-sectional surveys at baseline and at follow-up respectively. In addition, the medical records of 1224 women who had at least one antenatal care visit were followed in the longitudinal study. Women who had their ANC visit in the intervention health centers were significantly more likely to deliver their baby in the same health center compared to the control group (43.1% versus 28.4%; Adjusted Odds Ratio (AOR): 1.98 (95%CI 1.53–2.55)). A significantly higher percentage of women who had ANC in the intervention group had PNC in the same health center compared to the control health centers (41.2% versus 21.1%: AOR: 2.77 (95%CI 2.12–3.61)).

Conclusions

Our findings demonstrated that a locally customized mHealth application during ANC can significantly improve delivery and postnatal care service utilization possibly through positively influencing the behavior of health workers and their clients.

Paving the way for universal family planning coverage in Ethiopia: an analysis of wealth related inequality

BACKGROUND

Family planning plays a significant role in reducing maternal and child mortality and ultimately in achieving national and international development goals. It also has an important role in reducing new pediatric HIV infections by preventing unwanted pregnancies among HIV positive women. Investing in family planning is one of the smart investments for development as population dynamics have a fundamental influence on the pillars of sustainable development, including that of a sustainable environment.

OBJECTIVE

To identify and quantify wealth related differences in family planning use between poor and rich Ethiopian women based on the Demographic and Health Survey asset based wealth quintiles.

METHODS

The proportion of women who used contraceptives during implementation of the 2011 and 2005 Ethiopia Demographic and Health Surveys was calculated across wealth quintiles. Data were stratified for place of residence to analyze and determine inequalities in family planning use separately for rural and urban women. Socioeconomic inequalities according to wealth were measured using the slope index of inequality and the relative index of inequality.

RESULT

The absolute difference of contraceptive prevalence between poorest and richest women was over 25.3 percentage points (95% CI = 18.9-31.7) in 2011. Contraceptive use was more than twice (RII: 2.6, 95% CI = 2.0 - 3.3) as prevalent among the richest compared with the poorest.

CONCLUSION

Despite efforts to provide contraceptives for free at all public health facilities, wealth based inequalities still prevail in Ethiopia. People at lower socioeconomic strata should be empowered more to avoid the root causes of inequality and to achieve national Health Sector Development Program Goals.

Fertility desire and family-planning demand among HIV-positive women and men undergoing antiretroviral treatment in Addis Ababa, Ethiopia

Little information exists about desire to have children and family-planning use among HIV-positive individuals and how this may vary according to individual, social, health and demographic characteristics, especially in developing countries. To assess these topics in Ethiopia, a facility-based cross-sectional study was undertaken among 460 HIV-positive individuals receiving follow-up care at antiretroviral treatment (ART) centres in six public hospitals in Addis Ababa in 2006. One hundred and nine of the women (44.7%), 76 of the men (35.2%), and 40.2% overall of the HIV-positive individuals receiving care desired to have children. In comparison to those who said they did not desire to have children, those who did desire children tended to be younger (18-29 years) (adjusted odds ratio [OR]: 3.05, 95% CI: 1.5-6.4), married or in a relationship (adjusted OR: 3.4, 95% CI: 2.1-5.6), without a child (adjusted OR: 11.5, 95% CI: 5.3-24.9), and with a partner who also desired to have children (adjusted OR: 38.7, 95% CI: 16.7-89.1). Two hundred and forty-six individuals (53.5%) were using family planning (e.g. condoms, abstinence, injectables) and 85 wanted to use family planning in the future. The fertility desire and family-planning needs of these ART clients have implications for preventing vertical and heterosexual transmission of HIV, and the need for appropriate counselling and delivery of services.

Antiretroviral Therapy and Pregnancy Outcomes in Developing Countries: A Systematic Review

BACKGROUND

Despite significant efforts to understand adverse pregnancy outcome in women receiving Antiretroviral Therapy (ART), ART-related adverse birth outcomes are still poorly understood. We systematically review ART-related adverse birth outcomes among HIV-infected pregnant women; we also review the covariates associated with adverse birth outcomes in the aforementioned group.

METHODS

The main source for our systematic review was electronic bibliographic databases. Databases such as MEDLINE, PubMed, EMBASE and AIDSLINE were searched. Furthermore, search engines such as Google and Google Scholar were specifically searched for gray literature. Methodological quality of available literature was assessed using the Newcastle - Ottawa Quality Assessment Scale & M. Hewitt guideline. We examined a total of 1,124 papers and reviewed the studies using the PICOT criteria which stands for Patient (population), Intervention (or "Exposure"), Comparison, Outcome and Type of study. Finally, 32 methodologically fit studies were retained and included in our review.

RESULTS

Frequently observed adverse birth outcomes included low birth weight (LBW), Preterm Birth (PB), Small for Gestational Age (SGA), while still birth and congenital anomalies were infrequent. Type of regimen such as Protease Inhibitor (PI) based regimens and timing of initiation of ART are some of the factors associated with adverse pregnancy outcomes. Covariates principally included malnutrition and other co-morbidities such as malaria and HIV.

CONCLUSIONS AND PUBLIC HEALTH IMPLICATIONS

There is growing evidence in published literature suggesting that ART might be causing adverse birth outcomes among pregnant women in developing countries. There is a need to consider regimen types for HIV-infected pregnant women. There is need to design large cohort studies.

Is Community Conversation Associated with Human Immunodeficiency Virus Voluntary Counseling and Testing Service Uptake in Rural Communities in Ethiopia? A Comparative Cross-sectional Study

Background:

Voluntary counseling and testing (VCT) is a cost-effective tool to prevent and control human immunodeficiency virus (HIV)/acquired immodeficiency syndrome. Community conversation (CC) is a community-based strategy meant to enhance the community utilization of VCT. However, the role of CC in VCT service uptake has not yet been evaluated.

Aims:

This study was conducted to compare VCT service utilization between rural communities with well CC performance and rural communities with poor CC performance in Shebedino woreda.

Materials and Methods:

A cross-sectional comparative community-based study was conducted in 2010 among 462 selected adults in the age bracket of 15-59 years. VCT service uptake was compared between well CC performing communities and poor CC performing communities using two sample test of proportion. Predictors of VCT service uptake were determined using logistic regression model.

Results:

Uptake of VCT service and the related VCT knowledge were statistically higher in well CC performing communities than poor CC performing communities; [73.0% vs. 54.1%, P < 0.001) vs. 97.8% vs. 93.8%, P = 0.034]. CC, VCT knowledge, and knowledge on HIV transmission were independent predictors of VCT service utilization.

Conclusion:

Uptake of VCT service is higher in well CC performing communities. Emphasis should be given to strengthen CC performance.

Maternal morbidity in Butajira and Wukro districts, North and South central Ethiopia

BACKGROUND

Worldwide, for every woman that dies of maternal causes, there are at least 20 more women who suffer from infection, disabilities and injuries relating to pregnancy and childbirth.

OBJECTIVE

To determine the magnitude and the role of socio-economic, demographic and reproductive factors on the occurrence of maternal morbidity in the study population.

METHODS

During the months of January to February 2012, a community based cross sectional survey was conducted to assess magnitude and factors affecting maternal morbidity in selected kebeles of Wukro and Butajira districts, Tigray and Southern Nation Nationalities and People's (SNNP) regions respectively, Ethiopia. A total of 4949 women who had deliveries in the two years preceding the survey were included. Following description of variables under the study, bivariate and Multivariable statistics were used to see the relationship between different factors and maternal morbidity.

RESULTS

A total of 688 (14.2%) women reported that they had at least one form of morbidity. The three most frequent reported maternal morbidity during antenatal period were severe headache 89 (17.2%), lower abdominal pain (15.1%) and excessive vomiting (11.4%). Of the 220 women who reported to have morbidity during labor and delivery, prolonged labor (more than 24 hours) was accounted for 89 (40.5%) followed by hemorrhage and premature rapture of membranes in 74 (33.6%) and 23 (10.5%) of the cases respectively. Lower proportion of maternal morbidity was reported in Wukro than Butajira district [AOR (95% CI) = 0.17 (0.12, 0.25)]. Poorest and poor women were more likely to report to be sick [AOR (95% CI) = 1.79 (1.10, 2.91)] and [AOR (95% CI) = 1.65 (1.10, 2.47)] respectively. Women with parity of 5-6 and > or = 7 children respectively were also more likely to be morbid [AOR (95% CI) = 1.52 (1.11, 2.09)] and [AOR (95% CI) = 2.01 (1.38, 2.91)]. Women who had facility delivery were found more likely to have reported maternal morbidity with [AOR (95% CI) = 3.73 (2.96, 4.71)]

CONCLUSION

High parity, wealth status and facility delivery were found to be independent predictors of maternal morbidity. Empowering women through improving their resource generation capacity, and access to family planning services to those with high parity would diminish the likelihood of having maternal morbidity.

The effects of pregnancy intention on the use of antenatal care services: systematic review and meta-analysis

BACKGROUND

There has been considerable debate in the reproductive health literature as to whether unintended pregnancy influences use of maternal health services, particularly antenatal care. Despite the wealth of studies examining the association between pregnancy intention and antenatal care, findings remain mixed and inconclusive. The objective of this study is to systematically review and meta-analyse studies on the association between pregnancy intention and antenatal care.

METHODS

We reviewed studies reporting on pregnancy intention and antenatal care from PubMed, Popline, CINHAL and Jstor search engines by developing search strategies. Study quality was assessed for biases in selection, definition of exposure and outcome variables, confounder adjustment, and type of analyses. Adjusted odds ratios, standard errors and sample size were extracted from the included studies and meta-analyzed using STATA version 11. Heterogeneity among studies was assessed using Q test statistic. Effect-size was measured by Odds ratio. Pooled odds ratio for the effects of unintended pregnancy on the use of antenatal care services were calculated using the random effects model.

RESULTS

Our results indicate increased odds of delayed antenatal care use among women with unintended pregnancies (OR 1.42 with 95% CI, 1.27, 1.59) as compared to women with intended pregnancies. Sub-group analysis for developed (1.50 with 95% CI, 1.34, 1.68) and developing (1. 36 with 95% CI, 1.13, 1.65) countries showed significant associations. Moreover, there is an increased odds of inadequate antenatal care use among women with unintended pregnancies as compared to women with intended pregnancies (OR 1.64, 95% CI: 1.47, 1.82). Subgroup analysis for developed (OR, 1.86; 95% CI: 1.62, 2.14) and developing (OR, 1.54; 95% CI: 1.33, 1.77) countries also showed a statistically significant association. However, there were heterogeneities in the studies included in this analysis.

CONCLUSION

Unintended pregnancy is associated with late initiation and inadequate use of antenatal care services. Hence, women who report an unintended pregnancy should be targeted for antenatal care counseling and services to prevent adverse maternal and perinatal outcomes. Moreover, providing information on the importance of planning and healthy timing of pregnancies, and the means to do so, to all women of reproductive ages is essential.

Acute flaccid paralysis surveillance status and community awareness in pastoralist and semi-pastoralist communities of Ethiopia

BACKGROUND

Acute flaccid paralysis (AFP) surveillance is an essential component of the polio eradication strategy. The last laboratory confirmed wild poliovirus in Ethiopia was identified in April 2008. However, the country remains at risk for re-infection because of a number of silent areas and borders with high risk countries.

OBJECTIVE

Assess AFP surveillance status and community perception on AFP/Polio in semi pastoralist and pastoralist areas.

METHODS

Community and facility based cross-sectional survey was conducted complemented by Focus Group Discussions (FGD) from March - April, 2012. The study populations included District and health center AFP surveillance focal persons, WHO surveillance officers, community and religious leaders and women who delivered in the previous one year in purposively selected districts in Core Group Polio Project Implementation areas of Ethiopia.

RESULT

Interviews with health center and district AFP surveillance focal persons revealed deficiencies in training, supervision and feedback. The performance of AFP detection varied in the study districts and knowledge about polio and AFP detection was found to be low in the study communities.

CONCLUSION

There is a need to strengthen awareness of communities through targeted information, education and communication (IEC) interventions. Regular need-based training and supportive supervision should be conducted, involving all stakeholders including religious leaders and community leaders at each step of the awareness creation process, case detection and reporting and by giving special emphasis to silent and border districts.

Knowledge of mothers on poliomyelitis and other vaccine preventable diseases and vaccination status of children in pastoralist and semi-pastoralist areas of Ethiopia

BACKGROUND

Awareness and service utilization are key to polio eradication.

OBJECTIVE

Assess the knowledge of mothers on polio and other vaccine preventable diseases, and utilization of immunization services in pastoralist and semi-pastoralist areas in Ethiopia.

METHODS

A community-based cross sectional study using a multistage cluster sampling method involving women who delivered during the previous one year was conducted.

RESULTS

A total of 600 women were interviewed. Three hundred-and-five (50.8%) women said they knew what polio was. The time to initiate polio vaccination was correctly indicated to be at birth or within 2 weeks of birth by 224 (37.4%) women. Four hundred forty five (74.2%) women said they did not know how polio is transmitted Polio birth dose (Polio 0) and Polio 3 vaccine coverage were estimated at 32% and 37% respectively. Adjusting for other factors, knowledge of when polio vaccination starts was significantly associated with having a child vaccinated for Polio 3 (OR 95% CI = 3.45 (2.33- 5.11).

CONCLUSION

Knowledge of mothers about polio is low and a little more than one third were aware of when the initial vaccine dose should be administered. Providing detailed information on polio and the recommended vaccination schedule can contribute to improve immunization and hasten polio eradication.

Newborn tracking for polio birth dose vaccination in pastoralist and semi-pastoralist CORE Group Polio Project implementation districts (woredas) in Ethiopia

BACKGROUND

Estimates of immunization coverage rates in Ethiopia varied widely, but were consistent in that polio birth dose coverage is much lower than other antigens, particularly in semi-pastoralist and pastoralist areas.

OBJECTIVE

Examine pregnancy and child delivery practices and identify mechanisms for improving polio birth dose coverage in CORE Group Polio Project implementation districts.

METHODS

A community based cross sectional study was conducted in March - April 2012 involving 600 women who delivered in the previous one year. Interviews were also conducted with key informants, Traditional Birth Attendants and, Health Extension Workers complemented by Focus Group Discussions (FGDs) with community leaders.

RESULTS

Three hundred twelve women (52.0%) had attended antenatal care at least once during the last pregnancy. Five hundred forty nine women (91.5%) delivered their last baby at home. Polio coverage was 29.7%, 19.7%, and 32.7% by history, by card and by history or card respectively. Antenatal care attendance was the main predictor of polio birth does utilization adjusted for other factors. Discussion with FGD participants revealed the prevailing knowledge on polio including misconceptions, and immunization service utilization.

CONCLUSIONS

Newborn tracking for improving polio birth dose requires raising awareness among women and the community at large, strengthening mechanisms for identification and follow up of pregnant women at the community level, coordinating and strengthening the activities of front line health workers, and improving accessibility of health service.

Cross-border wild polio virus transmission in CORE Group Polio Project areas in Ethiopia

BACKGROUND

Ethiopia interrupted indigenous polio transmission in April 2008. However, it remains at risk of reinfection because of importation of polio virus from bordering countries.

OBJECTIVES

Assess polio immunization activities and risk of wild polio virus (WPV) importation in CORE Group Polio Project (CGPP) international border areas of Ethiopia.

METHODS

The study employed key informant interviews of community volunteers (CV), health extension workers (HEWs), program coordinators, managers and other stakeholders, as well as focus group discussions (FGDs) with community and religious leaders in six border districts (woredas) located in three regions of the country. It was conducted in March and April 2012.

RESULTS

Thirty-three key informant interviews and six FGDs were conducted. Immunization coverage was reported to be low and misconceptions about causes and transmission of polio were abundant. There was extensive cross-border movement of people for various reasons and mechanisms for prevention of cross-border polio transmission was almost non existent. AFP case detection and reporting was generally low.

CONCLUSION AND RECOMMENDATIONS

Cross-border transmission of polio can occur from several frontiers. Suggestions to control cross-border polio transmission included establishing and/or strengthening cross-border collaboration with responsible counterparts in neighboring countries by using existing cross-border forums and structures to create community awareness, share information and resources, design and implement strategies for identification of children who are eligible for vaccination or suspected AFP cases. In addition districts should coordinate supplemental immunization activities to coincide with when adjacent districts in neighboring countries are carrying out similar actions.

Factors associated with immunization coverage among children age 12-23 months: the case of Zone 3, Afar Regional State, Ethiopia

BACKGROUND

Strengthening routine immunization is one of the four pillars of the global polio eradication initiative.

OBJECTIVES

To determine the magnitude and factors associated with vaccination coverage among children age 12 -23 months in Zone 4 of Afar Regional State, Ethiopia.

METHODS

A community based cross-sectional study using the WHO modified cluster sampling method was carried out in Zone 3 of Afar Regional State between January 01 and May 31, 2009. The calculated sample size was 762 and 740 were included in the analysis of vaccination status.

RESULTS

A total of 740 children aged 12-23 months were included in the study. Three hundred forty two (46%) respondents reported that their children were vaccinated at least once. Polio 3 coverage was found to be 35.0% and full immunization coverage was 20.6%. Respondents who could read and write had a higher likelihood of getting their children vaccinated compared to those who could not read or write [AOR = 0.18, 95% CI: 0.08-0.34]. Similarly age of the mother, husband's attitude and joint decision making by husband and wife were significantly associated with child immunization adjusted for other factors.

CONCLUSION

The population immunity for polio measured by routine polio vaccine uptake in the study area indicated a high risk for wild polio virus outbreaks following importations, and the emergence and spread of circulating vaccine- derived polio virus. Literacy, positive attitude towards immunization and decision power are important factors to be addressed.

Health facility preparedness for routine immunization services in Gambella region, Ethiopia

BACKGROUND

Immunization coverage has been consistently low in semi pastoralist regions of Ethiopia, including the Gambella region.

OBJECTIVE

Assess facility preparedness for routine immunization services in the region.

METHODS

All health centers and randomly selected health posts that were reported to provide immunization services for at least six months earlier to the data collection time were included. The study was conducted in August, 2011. Data were collected through observations and interviewing health facility head or EPI focal person using structured questionnaire.

RESULT

Only 7/28 (25%) of health facilities provided routine EPI service regularly while the rest 21/28 (75%) health facilities did not offer routine EPI regularly. The reasons given for not providing EPI services regularly were lack of refrigerator in 9/28 (32.1%) health facilities, shortage of kerosene in 7/28 (33.3%), the refrigerators were dysfunctional in 3/28 (14.3%), had no vaccine in 1/28 (3.6%) health facilities. At times higher coverage were attained when Enhance Routine Immunization Activities (ERIA) were conducted.

CONCLUSION

Routine EPI performance in Gambella region is generally low. There seems to be reliance only on ERIAs to increase EPI coverage. Health facilities should be staffed with trained personnel and adequate immunization logistics should be available to run regular static and outreach services.

Knowledge and practice of frontline health workers (Health Extension Workers and Community Volunteer Surveillance Focal Persons) towards acute flaccid paralysis (AFP) case detection and reporting in pastoralist and semi-pastoralist areas of Ethiopia

BACKGROUND

Front line workers in pastoralist and semi pastoralist areas are expected to play a vital role in detecting cases of Acute Flaccid Paralysis.

OBJECTIVE

Assess knowledge and practice of Heath Extension Workers (HEWs) and Community Volunteer Surveillance Focal Persons (CVSFPs) on AFP case detection and reporting.

METHODS

A cross sectional survey involving 70 Health Extension Workers (HEWs) and 71 Community Volunteer Surveillance Focal Persons (CVSFPs) was conducted in 9 districts in Core Group Polio Project Implementation areas of Ethiopia from March 1-April 30, 2013. Data were entered and analyzed using SPSS version 17.

RESULTS

Thirty four HEWs (48.6%) searched for AFP cases by going from house to house, while 27 (38.6%) did not perform any function specific to AFP surveillance. Twenty (28.2%) and 7 (9.9%) of CVSFPs respectively, indicated using a case definition of AFP which included paralysis and acute paralysis. Nine (12.7%) of the CVSPF provided responses that did not include paralysis while 22 CVSFPs (31.0%) did not know the case definition of AFP. Three HEWs and 9 CVSFPs claimed to have detected and reported AFP cases. Thirty-eight (53.5%) CVSFPs had received training on community-based surveillance while 33 (46.5%) had none. Thirty nine (54.9%) of the CVSFPs reported having received supervision during the last six months, 22 (31.0%) of whom reported having received feedback.

CONCLUSION

Inadequate pertinent knowledge on AFP and inadequate training and supervision appear to be obstacles for effective AFP detection by front line health workers in the study communities.

The association of unwanted pregnancy and social support with depressive symptoms in pregnancy: evidence from rural Southwestern Ethiopia

BACKGROUND

Depression in pregnancy has adverse health outcomes for mothers and children. The magnitude and risk factors of maternal depression during pregnancy is less known in developing countries. This study examines the association between pregnancy intention, social support and depressive symptoms in pregnancy in Ethiopia.

METHODS

Data for this study comes from a baseline survey conducted as part of a community- based cohort study that involved 627 pregnant women from a Demographic Surveillance Site (DSS) in Southwestern Ethiopia. The Edinburgh Postnatal Depression Scale (EPDS) was used to measure depressive symptoms during pregnancy. Data on depressive symptoms, pregnancy intention, social support and other explanatory variables were gathered using an interviewer-administered structured questionnaire. The association between independent variables and depressive symptom during pregnancy was assessed using multivariable logistic regression.

RESULTS

The prevalence of depressive symptoms during pregnancy was 19.9% (95% CI, 16.8-23.1), using EPDS cut off point of 13 and above. The mean score on the EPDS was 8, ranging from 0 to 25 (SD ±5.4). Women reporting that the pregnancy was unwanted were almost twice as likely to experience depressive symptoms compared with women with a wanted pregnancy. (Adjusted Odds Ratio (AOR) = 1.96, 95% Confidence Interval (CI) 1.04-3.69) Women who reported moderate (AOR = 0.27; 95% CI 0.14-0.53) and high (AOR = 0.23, 95% CI 0.11-0.47) social support during pregnancy were significantly less likely to report depressive symptoms. Women who experienced household food insecurity and intimate partner physical violence during pregnancy were also more likely to report depressive symptoms.

CONCLUSION

About one in five pregnant women in the study area reported symptoms of depression. While unwanted pregnancy increases women's risk of depression, increased social support plays a buffering role from depression. Thus, identifying women's pregnancy intention and the extent of social support they receive during antenatal care visits is needed to provide appropriate counseling and improve women's mental health during pregnancy.

The effect of health facility delivery on neonatal mortality: systematic review and meta-analysis

BACKGROUND

Though promising progress has been made towards achieving the Millennium Development Goal four through substantial reduction in under-five mortality, the decline in neonatal mortality remains stagnant, mainly in the middle and low-income countries. As an option, health facility delivery is assumed to reduce this problem significantly. However, the existing evidences show contradicting conclusions about this fact, particularly in areas where enabling environments are constraint. Thus, this review was conducted with the aim of determining the pooled effect of health facility delivery on neonatal mortality.

METHODS

The reviewed studies were accessed through electronic web-based search strategy from PUBMED, Cochrane Library and Advanced Google Scholar by using combination key terms. The analysis was done by using STATA-11. I(2) test statistic was used to assess heterogeneity. Funnel plot, Begg's test and Egger's test were used to check for publication bias. Pooled effect size was determined in the form of relative risk in the random-effects model using DerSimonian and Laird's estimator.

RESULTS

A total of 2,216 studies conducted on the review topic were identified. During screening, 37 studies found to be relevant for data abstraction. From these, only 19 studies fulfilled the preset criteria and included in the analysis. In 10 of the 19 studies included in the analysis, facility delivery had significant association with neonatal mortality; while in 9 studies the association was not significant. Based on the random effects model, the final pooled effect size in the form of relative risk was 0.71 (95% CI: 0.54, 0.87) for health facility delivery as compared to home delivery.

CONCLUSION

Health facility delivery is found to reduce the risk of neonatal mortality by 29% in low and middle income countries. Expansion of health facilities, fulfilling the enabling environments and promoting their utilization during childbirth are essential in areas where home delivery is a common practice.

Maternal intimate partner violence victimization and under-five children mortality in Western Ethiopia: a case-control study

OBJECTIVE

This study aimed to compare the association between maternal intimate partner violence and under-five mortality.

METHODS

Matched case-control study was conducted from May to June 2011. A sample of 286 cases and 572 controls were randomly selected from East Wollega Zone, West Ethiopia.

RESULTS

Among cases, 72.7% ever experienced controlling behaviors when compared to 62.4% for controls. All forms of maternal intimate partner violence were experienced by 61.9% of cases and 50.9% of controls. Controlling behavior in marriage and experiences of all forms of intimate partner violence during lifetime were more than four [adjusted odds ratio (AOR) 4.27, 95% confidence interval (CI) 0.97-18.89), and two (AOR = 2.55, 95% CI 1.66-3.92) times as likely to be associated with under-five mortality.

CONCLUSION

Maternal intimate partner violence victimization is strongly associated with under-five mortality. Involving men in maternal and child health programs could be one strategy to address the issue of intimate partner violence against women.

Demand for long acting and permanent contraceptive methods and associated factors among family planning service users, Batu town, Central Ethiopia

BACKGROUND

Evidence suggests a high unsatisfied demand for long acting and permanent contraceptive methods in sub-Saharan Africa. However, there is limited knowledge on demand for long acting and permanent contraceptive methods and associated factors in Ethiopia.

OBJECTIVE

The objective of this study was to assess demand for long acting and permanent contraceptive methods and associated factors among women of age group 18-49 years in Batu town, East Shoa Zone, Ethiopia.

METHODOLOGY

A facility based cross-sectional survey was conducted in six service delivery points from March to April 2009 on 398 women of age 18-49 years old.

RESULTS

Thirteen (3%) were using long acting and permanent contraceptive methods and 89 (22.4%) wanted no more child in the future making the total demand of long acting and permanent contraceptive methods 24.4%. Older age group, multiparty, that the provider asked about reproductive intention, and the provider explained side effects of method selected were significantly associated with using LA and MPs (P < 0.05).

CONCLUSION

There is high total demand and several socio demographic and family planning service quality related factors were associated with demand for long acting and permanent contraceptive methods indicating that multi-dimensional measures are needed to improve the use of long acting and permanent contraceptive methods.

The effect of intimate partner violence against women on under-five children mortality: a systematic review and meta-analysis

INTRODUCTION

Intimate partner violence against women is one of the most common and widely occurring forms of violence against women that had consequences on the health of women and children. However, studies of the impact on children mortality reported controversial results.

OBJECTIVES

To determine the overall magnitude, association directions of intimate partner violence against women and mortality among under five children.

METHODS

Online databases were systematically searched for subject heading intimate partner violence against women and under five children mortality. On the final search 11 studies from developing countries were inputted into Metaesy add-in for MS Excel version 1.0.4 software for meta-analysis. Random effect model using DerSimonian and Laird's (DL) estimator was used to calculate the pooled estimates of the studies.

RESULTS

Mother who reported past experiences of intimate partner violence were more likely to have under-five children mortality. Mean effect size, 95% CI; 0.23 (0.16 to 0.32) was observed which is significantly different from Zero. The value of pooled Odds Ratio corresponds to 95% CI is: 1.34 (1.12 to 1.46).

CONCLUSIONS

Interventions aimed at improving child health and survival should focus to protect women from all forms of violence. Comprehensive and longitudinal studies are encouraged to address the issues of intimate partner violence against women and under five children mortality in more depth.

The Standard Days Method: an addition to the arsenal of family planning method choice in Ethiopia

BACKGROUND AND METHODOLOGY

The Standard Days Method ® (SDM) is a fertility awareness-based method of family planning that helps users to identify the fertile days of the reproductive cycle (Days 8-19). To prevent pregnancy users avoid unprotected sexual intercourse during these days. A cross-sectional community-based study was conducted from December 2007 to June 2008 in four operational areas of Pathfinder International Ethiopia. A total of 184 SDM users were included in the study. Quantitative and qualitative methods of data collection were used. The aim of the study was to examine the experience of introducing the SDM at community level in Ethiopia.

RESULTS

Of the 184 participants, 80.4% were still using the SDM at the time of the survey, with 35% having used it for between 6 and 12 months, while 42% had used it for more than a year. The majority (83%) knew that a woman is most likely to conceive halfway through her menstrual cycle, and nearly 91% correctly said that the SDM does not confer protection from sexually transmitted infections/AIDS. A substantial majority (75%) had correctly identified what each colour-coded bead represents in the CycleBeads ®, and an aggregate of 90.5% of women practised all the elements of correct use.

DISCUSSION AND CONCLUSIONS

This study demonstrates the importance of the SDM in increasing the availability and accessibility of family planning, and the potential to improve family planning method choice and method mix by expanding use of the SDM.

Sexual and reproductive health status and related problems of young people with disabilities in selected associations of people with disability, Addis Ababa, Ethiopia

BACKGROUND

Young people in Ethiopia face many sexual and reproductive health problems. In particular young people with disability are among the most stigmatized, poorest, and least educated. To date, very little is known about the sexuality of disabled youth, in general the reproductive health need and related problems of this group.

OBJECTIVE

The aim of this study is to assess the sexual reproductive health status and associated problems of young people with disability at selected associations of people with disability in Addis Ababa.

METHOD

A cross-sectional survey was conducted from Feb 11-17, 2008 to assess disabled youth reproductive health status and related problems. Data were collected by trained interviewers using a structured questionnaire and two complementary focus group discussions were also conducted guided by semi-structured questions. A total of 384 young people with disability were selected using systematic sampling technique. The sociodemographic and the sexual reproductive health characteristics of the respondents were described and appropriate statistical methods including chi-square test, crude and adjusted odds ratio were used to make comparisons

RESULT

A total 174 (45.3%) of respondents in the study ever had sexual intercourse; out of which 100 (57.5%) and 74 (42.5%) were males and females respectively. Seventy three (42.0%) started sex between the age of 15-19 years and only 9.2% were married Only 45.4% of the sexually experienced respondents had used some kind of contraceptive during their first sexual encounter. The prevalence of unintended pregnancy was 62.5% among young disabled females who had ever been pregnant and 50% of them had history of abortion, 87.5% of this abortion was induced type. In this study, 58.6% of the sexually active respondents had multiple life time sexual partners, 20.7% had a casual sex partner and 18.0% of sexually active males had a commercial sex partner in the past 12 months period prior to the survey. The prevalence of history of ever having STI was 25.3% Only 55.5%, 33.1% and 51.8% of respondents had good knowledge on HIV transmission, STI Sign and symptom, HIV Prevention respectively and only 33.3% of respondents had utilized reproductive health services. Adjusting for socio-demographic variables, respondents' educational status, occupation, sex and forms of disability were found to have a significant association with modern contraceptive use (P < 0.05).

CONCLUSION & RECOMMENDATIONS

Young People with Disability (YPWD) are at great risk for sexual and reproductive health associated problems. Female young people with disability and the illiterate are the most disadvantaged Awareness of parents, family members and the community about the needs and the capabilities of YPWD should improve and they should work together with the government to provide a safe environment for YPWDs. Organizing programs focused on acquisition of essential skills (communication and negotiation skills) and provision of appropriate for YPWD sexual and reproductive health services deserve due emphasis.

Mortality measurement in transition: proof of principle for standardised multi-country comparisons

Objective

To demonstrate the viability and value of comparing cause-specific mortality across four socioeconomically and culturally diverse settings using a completely standardised approach to VA interpretation.

Methods

Deaths occurring between 1999 and 2004 in Butajira (Ethiopia), Agincourt (South Africa), FilaBavi (Vietnam) and Purworejo (Indonesia) health and socio-demographic surveillance sites were identified. VA interviews were successfully conducted with the caregivers of the deceased to elicit information on signs and symptoms preceding death. The information gathered was interpreted using the InterVA method to derive population cause-specific mortality fractions for each of the four settings.

Results

The mortality profiles derived from 4784 deaths using InterVA illustrate the potential of the method to characterise sub-national profiles well. The derived mortality patterns illustrate four populations with plausible, markedly different disease profiles, apparently at different stages of health transition.

Conclusions

Given the standardised method of VA interpretation, the observed differences in mortality cannot be because of local differences in assigning cause of death. Standardised, fit-for-purpose methods are needed to measure population health and changes in mortality patterns so that appropriate health policy and programmes can be designed, implemented and evaluated over time and place. The InterVA approach overcomes several longstanding limitations of existing methods and represents a valuable tool for health planners and researchers in resource-poor settings.

Spatio-temporal clustering of mortality in Butajira HDSS, Ethiopia, from 1987 to 2008

Background

Mortality in a population may be clustered in space and time for a variety of reasons, including geography, socio-economics, environment and demographics. Analysing mortality clusters can therefore reveal important insights into patterns and risks of mortality in a particular setting.

Objective and design

To investigate the extent of spatio-temporal clustering of mortality in the Butajira District, Ethiopia, from 1987 to 2008. The Health and Demographic Surveillance System (HDSS) dataset recorded 10,696 deaths among 951,842 person-years of observation, with each death located by household, in which population time at risk was also recorded. The surveyed population increased from 28,614 in 1987 to 62,322 in 2008, in an area approximately 25 km in diameter. Spatio-temporal clustering analyses were conducted for overall mortality and by specific age groups, grouping the population into a 0.01° latitude–longitude grid.

Results

A number of significantly high- and low-mortality clusters were identified at various times and places. Butajira town was characterised by significantly low mortality throughout the period. A previously documented major mortality crisis in 1998–1999, largely resulting from malaria and diarrhoea, dominated the clustering analysis. Other local high-mortality clusters, appreciably attributable to meningitis, malaria and diarrhoea, occurred in the earlier part of the period. In the later years, a more homogeneous distribution of mortality at lower rates was observed.

Conclusions

Mortality was by no means randomly distributed in this community during the period of observation. The clustering analyses revealed a clear epidemiological transition, away from localised infectious epidemics, over a generation.

Ageing of a rural Ethiopian population: who are the survivors?

OBJECTIVES

This study assessed trends in survival to old age and identified the factors associated with longevity among the elderly (age > or = 65 years).

STUDY DESIGN

Cohort analysis of demographic surveillance data.

METHODS

The study was conducted in the Butajira Rural Health Programme Demographic Surveillance Site in Ethiopia. Using data collected between 1987 and 2004, the probability of survival to 65 years and remaining life expectancy for women and men aged 65 years were computed. Cox regression analysis was used to assess survival by different factors.

RESULTS

Although the elderly represented 3% of the population, their person-time contribution increased by 48% over the 18-year period. Less than half reached 65 years of age, with remaining life expectancy at 65 years ranging from 15 years in rural men to 19 years in urban women. Rural residence, illiteracy and widowhood were associated with lower survival adjusted for other factors, whereas gender did not show a significant difference. However, the effect of these factors differed between men and women, as demonstrated by survival curves and Cox regression. Widowhood [hazard ratio (HR) 2.02, 95% confidence interval (CI) 1.59-2.57] and illiteracy (HR 2.26, 95% CI 1.86-2.73) affected males to a greater extent than females, and rural residence was associated with poorer female survival (HR 1.68, 95% CI 1.55-1.83).

CONCLUSIONS

The number of elderly people is increasing in Ethiopia, with the chance of survival into older age being similar between men and women and approaching that in developed countries. However, rural women and illiterate women and men, particularly widowers, are disadvantaged in terms of survival.

Vulnerability to episodes of extreme weather: Butajira, Ethiopia, 1998-1999

Background

During 1999–2000, great parts of Ethiopia experienced a period of famine which was recognised internationally. The aim of this paper is to characterise the epidemiology of mortality of the period, making use of individual, longitudinal population-based data from the Butajira demographic surveillance site and rainfall data from a local site.

Methods

Vital statistics and household data were routinely collected in a cluster sample of 10 sub-communities in the Butajira district in central Ethiopia. These were supplemented by rainfall and agricultural data from the national reporting systems.

Results

Rainfall was high in 1998 and well below average in 1999 and 2000. In 1998, heavy rains continued from April into October, in 1999 the small rains failed and the big rains lasted into the harvesting period. For the years 1998–1999, the mortality rate was 24.5 per 1,000 person-years, compared with 10.2 in the remainder of the period 1997–2001. Mortality peaks reflect epidemics of malaria and diarrhoeal disease. During these peaks, mortality was significantly higher among the poorer.

Conclusions

The analyses reveal a serious humanitarian crisis with the Butajira population during 1998–1999, which met the CDC guideline crisis definition of more than one death per 10,000 per day. No substantial humanitarian relief efforts were triggered, though from the results it seems likely that the poorest in the farming communities are as vulnerable as the pastoralists in the North and East of Ethiopia. Food insecurity and reliance on subsistence agriculture continue to be major issues in this and similar rural communities. Epidemics of traditional infectious diseases can still be devastating, given opportunities in nutritionally challenged populations with little access to health care.

From birth to adulthood in rural Ethiopia: the Butajira Birth Cohort of 1987

Long-term birth cohorts from developing countries are uncommon. Here a unique birth to 18-years cohort based on all births during 1987 in a rural area of Ethiopia is presented. This was the first year of the ongoing Butajira Rural Health Programme, since when the sampled population has been followed up in regular household visits. A total of 1884 livebirths in 1987 formed the cohort, corresponding to a birth rate of 0.31 per woman per year; the male : female ratio was 1.10. Perinatal mortality was 22 per 1000 livebirths, and infant mortality 65 per 1000 livebirths. Survival from birth to 18 years was 760 per 1000. Living in Butajira town had a considerable survival advantage compared with the surrounding villages. Most deaths were due to infections. Four per cent of the cohort experienced the death of their mothers before the age of 18 years, and 15 of the girls delivered their own children, suggesting that 1 in 25 women may bear a child before their eighteenth birthday in this community. The children in the cohort received no consequent special care or attention, and so they probably accurately represent the harsh realities of growing up in rural Ethiopia at the turn of the Millennium. The huge gaps between their experience and that of their contemporaries in more affluent settings are a scandal of the 21st century.

A rural Ethiopian population undergoing epidemiological transition over a generation: Butajira from 1987 to 2004

AIMS

To describe the epidemiological development of a rural Ethiopian population from 1987 to 2004 in terms of mortality and associated sociodemographic factors.

METHODS

A rural population comprising 10 communities was defined in 1987 and has since been followed by means of regular household visits. After an initial census, births, deaths and migration events were recorded, together with key background factors, on an open cohort basis. Over 97,000 individuals were observed during a total of over 700,000 person years.

RESULTS

The initial population of 28,614 increased by an average of 3.64% annually to 54,426 from 1987 to 2004, and also grew older on average. Birth and mortality rates fell, but were still subject to short-term variation due to external factors. Overall mortality was 13.5 per 1000 person years. Increasing mortality in some adult age groups was consistent with increasing AIDS-related deaths, but a new local hospital in 2002 may have contributed to later falls in overall mortality. Sex, age group, time period, literacy, water source, house ownership and distance to town were all significantly associated with mortality differentials.

CONCLUSIONS

This population has undergone a complex epidemiological transition during a generation. Detailed long-term surveillance of this kind is essential for describing such processes. Many factors that significantly affect mortality cannot be directly controlled by the health sector and will only improve with general development.

Young adult and middle age mortality in Butajira demographic surveillance site, Ethiopia: lifestyle, gender and household economy

BACKGROUND

Public health research characterising the course of life through the middle age in developing societies is scarce. The aim of this study is to explore patterns of adult (15-64 years) mortality in an Ethiopian population over time, by gender, urban or rural lifestyle, causes of death and in relation to household economic status and decision-making.

METHODS

The study was conducted in Butajira Demographic Surveillance Site (DSS) in south-central Ethiopia among adults 15-64 years old. Cohort analysis of surveillance data was conducted for the years 1987-2004 complemented by a prospective case-referent (case control) study over two years. Rate ratios were computed to assess the relationships between mortality and background variables using a Poisson regression model. In the case-referent component, odds ratios (95% confidence intervals) were used to assess the effect of certain risk factors that were not included in the surveillance system.

RESULTS

A total of 367,940 person years were observed in a period of 18 years, in which 2860 deaths occurred. One hundred sixty two cases and 486 matched for age, sex and place of residence controls were included in the case referent (case control) study. Only a modest downward trend in adult mortality was seen over the 18 year period. Rural lifestyle carried a significant survival disadvantage [mortality rate ratio 1.62 (95% CI 1.44 to 1.82), adjusted for gender, period and age group], while the overall effects of gender were negligible. Communicable disease mortality was appreciably higher in rural areas [rate ratio 2.05 (95% CI 1.73 to 2.44), adjusted for gender, age group and period]. Higher mortality was associated with a lack of literacy in a household, poor economic status and lack of women's decision making.

CONCLUSION

A complex pattern of adult mortality prevails, still influenced by war, famine and communicable diseases. Individual factors such as a lack of education, low economic status and social disadvantage all contribute to increased risks of mortality.

Obstetric fistula in rural Ethiopia

OBJECTIVES

To determine the prevalence of obstetric fistula in rural Ethiopia and identify the circumstances and barriers to care that enhance development of obstetric fistula and its health and social consequences.

DESIGN

A cross-sectional study.

SETTING

The study was conducted in seven out of eleven administrative regions of Ethiopia by visiting randomly selected houses in rural areas and identifying women who have or had obstetric fistula and interviewing them.

RESULTS

A total of 19,153 houses were visited. Untreated fistula prevalence was about 1.5 per 1000 amounting to approximately 26,819 women. Most of the patients were young women who delivered for the first time. Marriage took place early in life mostly through family arrangements or abduction. The median number of days in labour was three to eight.

CONCLUSION

Promotive measures such as increasing age at marriage, and identification and treatment of patients should be intensified. There is a great need in improving accessibility and affordability of basic and emergency obstetric services for rural communities. Curving the situation in the long run requires dealing with the problem of poverty and improvement in the status of women.

Malaria-related mortality based on verbal autopsy in an area of low endemicity in a predominantly rural population in Ethiopia

Background

Although malaria is one of the most important causes of death in Ethiopia, measuring the magnitude of malaria-attributed deaths at community level poses a considerable difficulty. Nevertheless, despite its low sensitivity and specificity, verbal autopsy (VA) has been the most important technique to determine malaria-specific cause of death for community-based studies. The present study was undertaken to assess the magnitude of malaria mortality in a predominantly rural population of Ethiopia using VA technique at Butajira Rural Health Programme (BRHP) Demographic Surveillance Site (DSS).

Methods

A verbal autopsy was carried out for a year from August 2003 to July 2004 for all deaths identified at BRPH-DSS. Two trained physicians independently reviewed each VA questionnaire and indicated the most likely causes of death. Finally, all malaria related deaths were identified and used for analysis.

Results

A verbal autopsy study was successfully conducted in 325 deaths, of which 42 (13%) were attributed to malaria. The majority of malaria deaths (47.6%) were from the rural lowlands compared to those that occurred in the rural highlands (31%) and urban (21.4%) areas. The proportional mortality attributable to malaria was not statistically significant among the specific age groups and ecological zones. Mortality from malaria was reckoned to be seasonal; 57% occurred during a three-month period at the end of the rainy season between September and November. About 71% of the deceased received some form of treatment before death, while 12 (28.6%) of those who died neither sought care from a traditional healer nor were taken to a conventional health facility before death. Of those who sought treatment, 53.3% were first taken to a private clinic, 40% sought care from public health facilities, and the remaining two (6.7%) received traditional medicine. Only 11.9% of the total malaria-related deaths received some sort of treatment within 24h after the onset of illness.

Conclusion

The results of this study suggest that malaria plays a considerable role as a cause of death in the study area. Further data on malaria mortality with a relatively large sample size for at least two years will be needed to substantially describe the burden of malaria mortality in the study area.

Women's involvement in household decision-making and strengthening social capital-crucial factors for child survival in Ethiopia

AIMS

To assess the influence of household decision making, social capital, socio-economic factors and health service use on under-five mortality.

SETTING

Butajira Demographic Surveillance Site, Ethiopia.

METHODS

A prospective case-referent design with a total of 209 under-five year old deaths occurring in an 18-month period, together with 627 referents matched for age, sex and community of residence were included. Questionnaires were administered to mothers or caretakers. Matched case control analysis investigated the effect of risk factors on mortality and the presence of avoidable factors was assessed for each death.

RESULTS

Lack of immunization was strongly associated with mortality (adjusted OR=9.8, 95% CI 5.9, 16.1). Low decision making capacity of women (adjusted OR=3.2 95% CI 2.0, 5.0) and low social capital scores (adjusted OR=1.9 95% CI 1.1, 3.5) were also related to high under-five mortality in multivariate analyses. Potentially avoidable household and health facility factors were identified, respectively in 71% and 40% of the deaths.

CONCLUSION

Combined efforts to improve women's involvement in household decision making, social capital and immunization may decrease the high child mortality in this setting where the level of poverty is high and no appreciable trend in child mortality decline has been noted over the years.

Comparative study of the characteristics of family planning service users and non-users in northwest Ethiopia

Three hundred and forty-four (49.6%) family planning users and 350 (50.4%) non-family planning users were included in a study to assess the factors that are associated with utilisation of family planning services at different levels of health institutions in northwest Ethiopia. Desire for (more) children was the most common reason (51.4%) for not using family planning services, followed by inadequate knowledge about family planning services (14.6%). A higher proportion of the non-users were illiterate, of lower parity, and had their last child under one year of age (P<0.05). In logistics regression analysis family planning was significantly lower in the illiterate. Positive husband's attitude had the strongest association (OR 9.3, 95% CI 4.6, 18.7) with family planning. In addition to programs that create demand for smaller well-spaced children, IEC and family planning services should target men and strong emphasis should be given to use of family planning methods in as early period after birth as possible.

Assessing a new approach to verbal autopsy interpretation in a rural Ethiopian community: the InterVA model

OBJECTIVE

Verbal autopsy (VA) -- the interviewing of family members or caregivers about the circumstances of a death after the event -- is an established tool in areas where routine death registration is non-existent or inadequate. We assessed the performance of a probabilistic model (InterVA) for interpreting community-based VA interviews, in order to investigate patterns of cause-specific mortality in a rural Ethiopian community. We compared results with those obtained after review of the VA by local physicians, with a view to validating the model as a community-based tool.

METHODS

Two-hundred and eighty-nine VA interviews were successfully completed; these included most deaths occurring in a defined community over a 1-year period. The VA interviews were interpreted by physicians and by the model, and cause-specific mortality fractions were derived for the whole community and for particular age groups using both approaches.

FINDINGS

The results of the two approaches to interpretation correlated well in this example from Ethiopia. Four major cause groups accounted for over 60% of all mortality, and patterns within specific age groups were consistent with expectations for an underdeveloped high-mortality community in sub-Saharan Africa.

CONCLUSION

Compared with interpretation by physicians, the InterVA model is much less labour intensive and offers 100% consistency. It is a valuable new tool for characterizing patterns of cause-specific mortality in communities without death registration and for comparing patterns of mortality in different populations.

Sustainability of community based family planning services: experience from rural Ethiopia

The important role of active Community Based Reproductive Health Services (CBRHS), formerly known us Community Based Distribution (CBD) of family planning program, in increasing contraceptive uptake has been reported from several studies. However, the sustainability of project based services has not been documented in Ethiopia. This study was conducted to assess the effectiveness and sustainability of community based Family planning services in rural communities of Ethiopia. The study was carried out in three sets of 30 peasant villages selected from five districts of Eastern Showa Zone in Ethiopia. Comparison was made between never former; and current CBRHS areas. Relevant information was collected using a structured and pre-tested questionnaire. The respondents were women in the reproductive age groups (15-49 years). Knowledge about contraception was higher in both former and current CBRHS communities as compared to never CBRHS areas [MH-OR (95% CI) = 6.89 (4.69, 10.17) and 12.48 (7.84, 20.25)], respectively. Ever use of modern contraception was significantly greater among women from former and current CBRHS communities as compared to never CBRHS communities [MH-OR (95% CI) = 3.75 (2.54, 5.97) and 5.72 (3.93, 9.39), respectively]. Current use of modern contraception methods was however significantly better only in current CBRHS areas [MH-OR (95% CI) = 2.42; (1.16, 5.37)]; there was no statistically significant difference with former CBRHS areas [MH-OR (95% CI) = 1.13; (0.51, 2.49)]. Results of this study indicate that the effect of CBRHS in raising the level of modern contraception use in rural communities is transient. In order to sustain the effects of a good community based family planning services appropriate mechanisms must be designed to motivate and enable women to continuously utilize the services.

Burden of diseases in Amhara region, Ethiopia

This community based cross sectional study was conducted to estimate the Burden of Diseases in Amhara region of Ethiopia in 1997 - 1998 A total of 7 urban and 14 rural kebeles (social administrative units) were included in four administrative zones where questionnaire on morbidity, disability and mortality were administered. A total of 17780 people were included in the study. The total DALY was 51775 per 100000 population. The highest number of DALY lost were obtained for acute respiratory tract infections (especially children), malaria, diarrhoea, tuberculosis, and maternal and perinatal causes. Communicable and maternal and perinatal problems contributed to about 68% of the DALY lost. Whereas the contribution of noncommunicable diseases was about 17%. Accidents and injuries accounted for 6.4% of the DALY lost. The rest 4.9% and 3.7% were attributed to long-term disabilities where the cause could not be determined and undetermined causes of death respectively. It appears that while the traditional public health problems still persist in high prevalence, the so called "diseases of civilization" are also emerging thus further stretching the available resources for health. The findings of this study can be used to design appropriate strategies and use health resources efficiently.