Impacts of COVID-19 on reproductive health service provision, access, and utilization in Ethiopia: Results from a qualitative study with service users, providers, and stakeholders

Ethiopia has made significant improvements to sexual and reproductive health (SRH) in recent decades, yet the COVID-19 pandemic brought new challenges to SRH service delivery. In the early months of the pandemic, health facility and health management information system data showed reductions in SRH service utilization, however more evidence is needed on ongoing SRH impacts to inform policy and program decision-making. Our study aimed to assess the impacts of COVID-19 on SRH service utilization and access from the perspective of providers, clients, and stakeholders in Addis Ababa and Amhara Regional State. We collected data from May through July 2021 via six focus group discussions with health service providers, 50 in-depth interviews with SRH service clients and 15 key informant interviews with policy and programmatic stakeholders. All audio recordings were transcribed and translated from Amharic into English. Data were coded and analyzed for content and themes using Excel and NVivo 10. We found that COVID-19 and associated public health mitigation measures had consequences on SRH prioritization, funding, and service delivery. Efforts to halt the spread of COVID-19, such as gathering and transportation restrictions, also reduced access to SRH services. Fear of infection, costly and inaccessible transportation, commodity stockouts, and limited service availability all impeded access to and use of SRH services. For some women, this meant losing timely access to contraception and subsequently facing unwanted pregnancies. Providers experienced increased workloads, anxiety, and stigma as possible sources of infection. Our findings offer useful learnings for program and policy stakeholders aiming to meet SRH needs during the pandemic, and during times of crisis more broadly.

Expanding contraceptive choice in Ethiopia: a comparative analysis of method mixes in post-abortion contraception versus routine family planning

Background: In Ethiopia, a low contraceptive prevalence and high unmet need coupled with skewed method mix clearly signify the need for comprehensive family planning delivery strategies.  Ipas implemented problem-focused intervention to improve service delivery standards and provide accessible, high-quality family planning services. This analysis seeks to compare the contraceptive method mix in routine and post-abortion contraception services and to suggest how multifaceted service delivery approaches can help address the unmet family planning need. Methods: The intervention was implemented in 127 public health facilities providing both routine and post-abortion contraception services, from 2010 to 2017.  The intervention focused on service delivery and program management gaps identified during the baseline assessment.  Service data regularly collected from intervention facilities and entered into a Microsoft Excel database to conduct descriptive analysis, review trends, and monitor progress. Results: Trend analysis of method choice patterns revealed that the share of method mix for long-acting reversible contraceptives(LARCs) rose from 3% in 2010 to 40% in 2017 in routine family planning service, whereas in the post-abortion contraception service, the share for LARCs climbed from 2% in 2010 to 62% in 2017(P<0.001).  Trend analysis of LARC uptake in post-abortion contraception revealed that implant use rose from 2% in 2010 to 54% in 2017, while intrauterine device (IUD) use increased from 0.1% in 2010 to 9% in 2017.  In routine program, proportion of implant acceptors increased from 3% in 2010 to 35% in 2017, while IUD acceptance increased far more slowly, from only 0.07% to 5% over the same period. Conclusions: Comprehensive contraceptive service delivery strategies, such as integration of family planning with other maternal health services can help the service to reach clients with a variety of needs, a key factor for a higher uptake of LARCs by abortion clients as compared to routine family planning program.

Increasing access to self-managed abortion through pharmacies: programmatic results and lessons from a pilot program in Oromia, Ethiopia

Despite increased availability of safe abortion following legal reform in Ethiopia, one-half of public sector abortion services are treatment of postabortion complications, indicating challenges meeting women's needs. Self-managed abortion (SMA)-the ability of pregnant people to manage their unwanted pregnancies with or without the support of a health care provider-is a safe, feasible, and acceptable option for women at gestational ages up to 12 weeks. Seeing the potential of SMA to vastly expand access to safe abortion and reduce postabortion complications, a pilot initiative targeting private pharmacies was implemented by the Ethiopian Ministry of Health, the Oromia Regional Health Bureau, and a non-profit organization. From December 2021 to March 2023, implementers trained and supported 41 pharmacies to provide SMA counseling and medical abortion drugs, with and without prescriptions, which was considered to contradict the legal framework at the time. Pharmacy clients' SMA experiences were documented in logbooks and via 21-day follow-up phone surveys. Thirty-two pharmacies (78%) supported 1,457 self-managed abortions during the pilot. Among clients with complete follow-up surveys (n = 1,233), 98.3% had a complete abortion without needing additional treatment. Only four clients (0.3%) reported a complication. The pilot demonstrated high demand for and feasibility of increasing access to quality SMA through private pharmacies in Ethiopia, but challenges remain due to the lack of a legal framework. We recommend providing multi-sector support on SMA to private pharmacies so they can in turn improve safe abortion accessibility by bringing safe, acceptable services closer to the people that need them.

Person-centered abortion care in public health facilities across four regions of Ethiopia: a cross-sectional quantitative study of client experiences

Introduction

Ethiopia has made remarkable progress in expanding access to and provision of comprehensive abortion care. However, complications due to unsafe abortion persist. As efforts to increase quality of comprehensive abortion care continue, evaluating service quality is critical. Although "women-centered" abortion care is a central component of Ethiopia's technical guidelines for safe abortion, research has mostly focused on access to care, availability of services, and meeting clinical criteria, rather than examining service quality from abortion clients' perspectives. This study assesses the quality of comprehensive abortion care (CAC) in public health facilities, from clients' perspectives, in four regions of Ethiopia to examine how person-centered care differs based on facility and service characteristics.

Methods

We conducted 1,870 client exit surveys in 2018 using structured questionnaires with women who received induced abortion or postabortion care services from 76 public health facilities across four regions: Tigray, Amhara, Oromia, and Southern Nations, Nationalities, and People's. We operationalized person-centered care by mapping 30 indicators of quality to five of the six domains in the Person-Centered Care Framework for Reproductive Health Equity developed by Sudhinaraset and colleagues (2017): dignity & respect; autonomy; communication & supportive care; trust, privacy, and confidentiality; and health facility environment. We calculated descriptive, bivariate, and multivariable statistics to examine associations between service characteristics and person-centered care.

Results

CAC clients reported high levels of person-centered care, with exceptionally positive experiences for outcomes in the dignity and respect and trust, privacy, and confidentiality domains. However, there was notable room for improving client experiences across three domains: autonomy, communication and supportive care, and health facility environment. Client-reported quality outcomes differed significantly by diagnosis (induced or postabortion care), region, health facility type, and procedure type. Clients in Amhara, clients at tertiary and primary hospitals, and clients who received postabortion care reported lower levels of person-centered care.

Discussion

The positive experiences reported by comprehensive abortion care clients bolster evidence of the impact of the Ethiopian government's strategy to increase abortion access in the public health sector. However, notable disparities exist for key subgroups, particularly those seeking postabortion care and people visiting tertiary and primary hospitals. Quality improvement efforts should concentrate on improving abortion clients' autonomy, communication and supportive care, and the health facility environment. The Ethiopian Ministry of Health and its partners must dedicate resources to improve postabortion care quality, integration of reproductive health services within CAC, and pain management for MA clients as vital interventions.

Laboratory capacity expansion: lessons from establishing molecular testing in regional referral laboratories in Ethiopia

Respiratory viruses contribute to high morbidity and mortality in Africa. In 2020, the Ohio State University's Global One Health Initiative, in collaboration with the Ethiopian Public Health Institute and the US Centers for Disease Control and Prevention, took action to strengthen Ethiopia's existing respiratory virus surveillance system through decentralization of laboratory testing and scale-up of national and regional capacity for detecting respiratory viruses. In August 2022, four regional laboratories were established, thereby raising the number of reference laboratories conducting respiratory virus surveillance to five. This article highlights lessons learned during implementation and outlines processes undertaken for laboratory scale-up and decentralization.