Effectiveness of couple-based health education on utilization of maternity waiting homes among pregnant women in rural Ethiopia: A study protocol for cluster-randomized trial.

Background: Maternity waiting homes are used to enhance women's access to health facilities in low-resource settings; however, its use remains low in Ethiopia. It is important to investigate strategies that can enhance the usage of maternity waiting homes in Ethiopia. Methods: The purpose of his study is to assess how well couple-focused health education works to increase maternal knowledge, attitudes, and use of maternity waiting homes in rural Ethiopia. A cluster-randomized trial with two parallel groups will be the study's design. Three hundred twenty samples will be drawn from 16 clusters (160 in each group). Clusters will be assigned to intervention or control groups using a restricted randomization with a 1:1 allocation ratio. Women who are in their 14-16 weeks of gestation, or in the early stages of their second trimester, along with their male partners, will participate in the study. Health education, home visits, and the distribution of leaflets will be the intervention packages. Discussion: The trial results will provide conclusive evidence on whether couple-based health education can improve women's access to maternity waiting homes in rural Ethiopia.

A phenomenological qualitative study of male-partners perspectives of maternity waiting homes in rural Ethiopia.

Background: The implementation of maternity waiting home (MWH) has been used as a strategy to improve maternal health outcomes in low-resource settings such as Ethiopia. However, MWH utilization is low in Ethiopia, and women's access to MWH depends largely on male partners' decisions. This study explored male-partners perspectives of MWHs including their experiences of paternal support in rural Ethiopia. Study design: An exploratory qualitative study with a phenomenological methodological orientation was performed. Methods: This study was conducted in Ana-Lemo and Gibe districts of Hadiya Zone, in rural Southern Ethiopia. The study participants were male partners. A purposive sampling technique was used to recruit 47 participants. Data were collected from May 10-25, 2023. Four focus group discussions, 15 in-depth interviews, and observations were conducted. The interviews were audio-recorded, transcribed and the thematic content analysis was performed using ATLAS.ti 7.1.4 software. Results: This study showed that male-partners participated in spousal communication and provided practical support such as sharing household chores and financial support; however, they did not accompany their spouses to health facilities. Long distances, lack of transportation, poor referral services, and perceived poor quality of care were barriers to maternal health services. Furthermore, male-partners demonstrated poor awareness and unfavorable attitudes of MWHs. Conclusions: Male-partners participated in spousal communication, shared household chores and provided financial support to their spouses; however, they did not accompany them to health facilities. They had poor awareness and unfavorable attitudes of MWHs. Creating awareness among male partners may improve their attitude towards MWHs and other maternal health services in rural Ethiopia.

Factors associated with knowledge and attitude towards maternity waiting homes among pregnant women: baseline results from a cluster-randomized trial in rural Ethiopia.

Ethiopia has implemented maternity waiting homes over the last several decades; however, its utilization is low. This study aimed to assess the factors associated with knowledge of and attitude towards maternity waiting homes among pregnant women in rural Ethiopia. The baseline survey was conducted from September 15 to October 30, 2022, in rural Southern Ethiopia. Survey data were collected from 320 women in their second trimester of pregnancy. The data analysis was performed using SPSS version 25. The mean age of the participants was 27.79 (SD ± 6.242) years. Nearly two-thirds (57.5%) of the participants had no formal education and more than three-fourths (72.5%) were housewives. Only approximately one-fourth (23.75%) of the participants used maternity waiting homes. Furthermore, 33.75% had good knowledge, 28.75% had favorable attitudes, and around one-fourth (26.25%) had good male partner involvement. Age group 30 to 39 years (AOR 4.78, 95% CI 1.12-20.36), household income (AOR 6.41, 95% CI 2.78-14.81), having pregnancy intention (AOR 2.63, 95% CI 1.21-5.73), and history of obstetric complications (AOR 6.72, 95% CI 2.81-16.07) were significantly associated with good knowledge about maternity waiting homes. Similarly, age group 30 to 39 years (AOR 4.23, 95% CI 1.14-15.65), household income (AOR 7.12, 95% CI 3.26-15.55), having pregnancy intention (AOR 2.57, 95% CI 1.21-5.47), and history of obstetric complications (AOR 5.59, 95% CI 2.30-13.59) were significantly associated with favorable attitudes towards maternity waiting homes. Providing health education and promoting male partner participation through educating couples may improve women's access to maternity waiting homes.

Effect of couple-based health education on male-partners knowledge and attitude towards maternity waiting homes in rural Ethiopia: a cluster-randomized trial.

This cluster-randomized controlled trial examined the effect of couple-based health education on male partners' knowledge and attitude towards maternity waiting homes (MWH) in rural Ethiopia. Sixteen clusters and 320 couples were randomly assigned to intervention group (receiving group health education, home visits and print health messages alongside usual care) or control group (receiving usual care). The Chi-square test was used to estimate statistical differences, and the difference-in-differences model was used to estimate the effect of the intervention. The generalized linear regression model was used to determine the odds of outcomes between the groups. Statistical significance was set at p < 0.05, with a 95% CI. There were no significant differences in baseline characteristics between the control and intervention groups. The net effect of the intervention on improving knowledge about MWHs, and attitude towards MWHs were 35.6% and 36.2%, respectively. The participants in the intervention group were 5.5 times more likely to have good knowledge about MWH (AOR 5.55, 95% CI 3.37-9.14) and 5.6 times more likely to have a favorable attitude towards MWH (AOR 5.61, 95% CI 3.45-9.10) compared to their counterparts. Health education provided to couples significantly improved male partners' knowledge and attitude towards MWHs in rural Ethiopia.Trial registration: ClinicalTrials.gov Identifier: NCT05015023.

Women's experiences of maternity waiting homes in sub-Saharan Africa: a qualitative systematic review protocol.

OBJECTIVE: The objective of this review is to synthesize women's experiences related to the use of maternity waiting homes in sub-Saharan Africa. INTRODUCTION: Most maternal deaths occur within resource-limited settings. Sub-Saharan Africa and Southern Asia account for around 86% of all maternal deaths worldwide, with sub-Saharan Africa alone contributing roughly two-thirds of all maternal deaths. The long distances that women must travel to reach health facilities has been highlighted as the main cause of maternal death. Maternity waiting homes have been recognized as a strategy to enhance maternal health outcomes by bringing women living in geographically isolated locations closer to health facilities. However, maternity waiting home utilization rates are low and vary across different settings. INCLUSION CRITERIA: The study population will be women (15 to 49 years of age) living in sub-Saharan Africa who have experiences related to maternity waiting home use. This may include experiences with service provisions during the final weeks of pregnancy and 2 weeks after childbirth. Stays of at least 1 day will be considered for inclusion. METHODS: Databases including MEDLINE, Web of Science, Scopus, and Hinari will be searched. Gray literature sources will include Google Scholar and MedNar. Studies published in English from January 2000 onward will be included. Two independent reviewers will screen the titles and abstracts, followed by an examination of full-text papers. Any disagreements will be handled through discussion or consultation with a third reviewer. Two reviewers will independently assess the methodological quality of included studies and extract the data. The articles will be meta-aggregated and presented in tabular or narrative format. SYSTEMATIC REVIEW REGISTRATION NUMBER: PROSPERO CRD42022306003.

Prevalence of and characteristics associated with operative vaginal birth at Mizan-Tepi University Teaching Hospital.

BACKGROUND: To observe prevalence, characteristics and outcomes associated with operative vaginal birth (OVB). METHODS: We compared spontaneous vaginal birth with OVB. RESULTS: Of 993 women, 759 (76.4%) experienced vaginal birth; 716 were spontaneous (94.3%), 14 (1.8%) underwent forceps-assisted birth and 29 (3.8%) had vacuum assistance. In a multivariable model of OVB (forceps and vacuum), compared with a midwife, general practitioners (OR 5.6, p = 0.04) and integrated emergency surgical officers (OR 42.8, p = 0.001) were more likely to attend. Women experiencing OVB were more likely to receive local anesthesia (OR 3.0, p = 0.009). CONCLUSION: OVB is used sparingly but safely at Mizan-Tepi University Teaching Hospital.

A mobile cesarean birth center as a solution to improve access to surgical birth in rural Ethiopia: a mixed methods research protocol.

BACKGROUND: As an evidence-based intervention to prevent maternal and neonatal morbidity and mortality, cesarean birth at rates of under 2%, which is the case in rural Southwest Ethiopia, is an unacceptable public health problem and represents an important disparity in the use of this life-saving treatment compared to more developed regions. The objective of this study is to explore an innovative clinical solution (a mobile cesarean birth center) to low cesarean birth rates resulting from the Three Delays to emergency obstetric care in isolated and underserved regions of Ethiopia, and the world. METHODS: We will use mixed but primarily qualitative methods to explore and prepare the mobile cesarean birth center for subsequent implementation in communities in Bench Sheko and West Omo Zones. This will involve interviews and focus groups with key stakeholders and retreat settings for user-centered design activities. We will present stakeholders with a prototype surgical truck that will help them conceive of the cesarean birth center concept and discuss implementation issues related to staffing, supplies, referral patterns, pre- and post-operative care, and relationship to locations for vaginal birth. DISCUSSION: Completion of our study aims will allow us to describe participants' perceptions about barriers and facilitators to cesarean birth and their attitudes regarding the appropriateness, acceptability, and feasibility of a mobile cesarean birth center as a solution. It will also result in a specific, measurable, attainable, relevant, and timely (SMART) implementation blueprint(s), with implementation strategies defined, as well as recruitment plans identified. This will include the development of a logic model and process map, a timeline for implementation with strategies selected that will guide implementation, and additional adaptation/adjustment of the mobile center to ensure fit for the communities of interest. TRIAL REGISTRATION: There is no healthcare intervention on human participants occurring as part of this research, so the study has not been registered.

Pregnancy outcomes at Mizan-Tepi University Teaching Hospital: A Comparison to the Ethiopian Demographic and Health Surveys.

BACKGROUND: To compare outcomes at Mizan-Tepi University Teaching Hospital to national and regional data and to plan quality improvement and research studies based on the results. METHODS: This study was a prospective hospital-based cross-sectional analysis of a convenience sample of 1, 000 women who delivered at Mizan-Tepi University Teaching Hospital. RESULTS: Our convenience sample was young (median age 24 years) with a primarily school level or less of education (68.6%). Only about 5% of women had a history of prior cesarean birth, 2.1% reported they were human immunodeficiency virus seropositive, and the median number of prenatal visits was four. Women were commonly admitted in spontaneous labor (84.5%), transferred from another facility (49.2%; 96.8% of which were referred from a health center), and had their fetal heart rate auscultated on admission (94.7%). Only 5.2% of women did not deliver within twenty-four hours and the cesarean birth prevalence was 23.4%. Many women were delivered by midwives (73.2%; all unassisted vaginal births), 89.2% were term deliveries, and 92.5% of neonatal birthweights were 2500 grams or heavier. Less than five percent of women delivered stillbirths (4.3%) and 5.7% of livebirths experienced neonatal death by the day of discharge. There were no maternal deaths in the cohort. CONCLUSION: The prevalence of stillbirth and neonatal death were the most notable findings, while there was no maternal death in the cohort.

Characteristics and Outcomes Associated with Cesarean Birth as Compared to Vaginal Birth at Mizan-Tepi University Teaching Hospital, Ethiopia.

INTRODUCTION: The objective of this study was to observe characteristics and outcomes associated with cesarean birth as compared to vaginal birth. METHODS: This study was a prospective hospital-based cross-sectional analysis of a convenience sample of 1, 000 women. Data was collected on admission, delivery, and discharge by trained physician data collectors on paper forms through chart review and patient interview. RESULTS: Data on mode of delivery was available for 993/1000 women (0.7% missing data), 23.4% of whom underwent cesarean. These women were less likely to have labored (84.5% versus 87.4%), more likely to have been transferred (62.0% versus 45.2%), more likely to have been admitted in early labor (53.0% versus 48.6%), more likely to be in labor for longer than 24 hours (10.7% versus 3.3%) and were less likely to have multiple gestation (7.7% versus 3.9%), p < 0.05. In a Poisson model, history of cesarean (aRR 2.0, p < 0.001), transfer during labor (RR 1.5, p = 0.003), labor longer than 24 hours and larger birthweight (RR 2.7, p 0.001) were associated with an increased risk of cesarean. CONCLUSION: Our analysis suggests cesarean birth is being used among women with a history of prior cesarean and in cases of labor complications (prolonged labor or transfer), but fresh stillbirth is still common in this setting.

Mode of Delivery Among Women with a History of Prior Cesarean Birth at Mizan-Tepi University Teaching Hospital.

OBJECTIVES: The objective of this study was to observe mode of delivery among women with a history of prior cesarean birth. METHODS: After collecting data on a convenience sample of 1,000 women giving birth at 28 weeks gestation or greater at Mizan-Tepi University Teaching Hospital, we reduced the sample to only include women with a history of prior cesarean birth. We wanted to observe mode of delivery among this cohort and determine if any characteristics were associated with elective repeat cesarean birth, as compared to vaginal birth after cesarean. RESULTS: Of 1,000 women in our convenience sample, data on history of prior cesarean birth was missing on 2 women (0.2%). Of the remaining women, 49 (4.9%) reported a history of prior cesarean; 44 (89.8%) reported one prior cesarean and 5 (10.2%) women had two prior cesarean births. Repeat cesarean birth occurred in 65.1% (n = 29/44) of women with one prior cesarean and in 80.0% (n = 4/5) of women with two prior surgeries. Among the total cohort of women with a history of prior cesarean birth, of those who experienced repeat cesarean birth (n = 33), 27.3% (n = 9) occurred pre-labor, 69.7% (n = 23) occurred intrapartum after the onset of spontaneous labor, and 3.0% (n = 1) occurred intrapartum during the course of an induced or augmented labor. Labor onset and cervical exam on admission were statistically significantly different in bivariate comparisons of women who successfully achieved vaginal birth after cesarean as compared to those who gave birth by repeat cesarean birth, and postpartum maternal antibiotics were more common after repeat cesarean birth, p < 0.05. In a multivariable model of factors associated with successful vaginal birth after cesarean, the likelihood of successful vaginal birth was increased 15% for each increasing centimeter of dilation on a woman's admission cervical exam (RR 1.15, p= 0.004). CONCLUSION: Almost one-third of women in our observational cohort attempted trial of labor after cesarean; those that were successful were more likely to have been more cervically dilated on their admission exam. No sociodemographic or obstetrical characteristics were more likely among women who underwent pre-labor repeat cesarean birth as compared to intrapartum cesarean birth.

Performance of Integrated Emergency Surgical Officers at Mizan-Tepi University Teaching Hospital, Mizan-Aman, Ethiopia: A Retrospective Cohort Study.

INTRODUCTION: Surgical physician extenders are used in Ethiopia and sub-Saharan Africa where there is a lack of surgical providers. METHODS: We tested characteristics associated with and outcomes of births attended by an integrated emergency surgical officers (IESOs) as compared to midwives and physician providers. RESULTS: Of 1,000 women in our convenience sample, data on birth attendant was missing on 5 women (0.5%). Of the remaining women, almost three-fourths (73.6%, n = 732) of women were attended by a midwife, almost a quarter were attended by an IESO (24.4%, n = 243), 10 women were attended by a physician with a General Practitioner level of training (1.0%), 5 women were delivered by an Ob/Gyn resident (0.5%), and 5 women were attended by an Ob/Gyn (0.5%). Women had a higher likelihood of being attended by an IESO than a midwife if they underwent forceps-assisted (RR 88.4, p < 0.05), vacuum-assisted (RR 45.2, p < 0.05), or cesarean birth (RR 161.8, p < 0.05) as compared to an unassisted vaginal birth. IESOs are performing more operative vaginal and cesarean births than other delivery providers. Outcomes of their deliveries are worse than those of midwives, but this is likely due to the acuity level of the patients and not the provider type.

Use of Cesarean Birth at Mizan Tepi University Teaching Hospital, Mizan Aman, Ethiopia.

OBJECTIVES: The objective of this analysis was to review indication and utilization of cesarean birth among Robson Classification of Cesarean Birth subgroups. METHODS: This study was a prospective hospital-based cross-sectional analysis of a convenience sample of 1,000 women who delivered Mizan Tepi University Teaching Hospital in the summer and fall of 2019. RESULTS: Data on mode of delivery was available for 993 women, 23.4% of which underwent cesarean birth. The leading indication for cesarean birth was a fetal indication (46.2%), followed by a maternal indication (35.9%); elective cesarean birth was the indication for one cesarean birth. Robson Groups 1 and 3 (primary cesarean among nulliparous and multiparous women) accounted for the largest proportion of the overall population of women (30.2% and 36.8%), and cesarean birth rates within these groups were 19.4% and 16.1%, respectively. In all remaining groups, cesarean birth rates were at least 17.1%, ranging to as high as 100.0%. Pre-labor cesarean was highest in Robson Group 5 (multiparous women with a history of cesarean birth). CONCLUSION: Further analysis of risk factors associated with cesarean birth in women whose labor was induced or augmented, or those undergoing preterm birth, might offer additional target risk factors to modify.

Use of Cesarean Birth among Robson Groups 2 and 4 at Mizan-Tepi University Hospital, Ethiopia.

BACKGROUND: Primary cesarean birth rates were high among women who were either nulliparous (Group 2) or multiparous (Group 4) with a single, cephalic, term fetus who were induced, augmented, or underwent cesarean birth before labor in our study cohort. OBJECTIVES: The objective of this analysis was to determine what risk factors were associated with cesarean birth among Robson Groups 2 and 4. METHODS: This study was a prospective hospital-based cross-sectional analysis of a convenience sample of 1,000 women who delivered at Mizan-Tepi University Teaching Hospital in the summer and fall of 2019. RESULTS: Women in Robson Groups 2 and 4 comprised 11.4% (n = 113) of the total population (n = 993). The cesarean birth rate in Robson Group 2 (n = 56) was 37.5% and in Robson Group 4 (n = 57) was 24.6%. In Robson Group 2, of all prelabor cesareans (n = 5), one birth was elective cesarean by maternal request; the intrapartum cesarean births (n = 16) mostly had a maternal or fetal indication (93.8%), with one birth (6.2%) indicated by "failed induction or augmentation," which was a combined indication. In Robson Group 4, all 4 women delivered by prelabor cesarean had a maternal indication (one was missing data), and 3 of the intrapartum cesareans were indicated by "failed induction or augmentation." In multivariable modeling of Robson Group 2, having a labor duration of "not applicable" increased the risk of cesarean delivery (RR 2.9, CI (1.5, 5.4)). The odds of requiring maternal antibiotics was the only notable outcome with increased risk (RR 11.1, CI (1.9, 64.9)). In multivariable modeling of Robson Group 4, having a labor longer than 24 hours trended towards a significant association with cesarean (RR 3.6, CI (0.9, 14.3)), and women had a more dilated cervix on admission trended toward having a lower odds of cesarean (RR 0.8, CI (0.6, 1.0)). CONCLUSION: Though rates of primary cesarean birth among women who have a term, single, cephalic fetus and are induced, augmented, or undergone prelabor cesarean birth are high, those that occur intrapartum seem to be associated with appropriate risk factors and indications, though we cannot say this definitely as we did not perform an audit. More research is needed on the prelabor subgroup as a separate entity.

Estimates of Uterine Rupture Bad Outcomes Using Propensity Score and Determinants of Uterine Rupture in Mizan-Tepi University Teaching Hospital: Case Control Study.

BACKGROUND: Uterine rupture is a tear in the wall of uterus which carries grave risks to the mother as well as her baby. OBJECTIVES: To estimate uterine rupture bad outcomes using propensity score and its determinants in Mizan-Tepi University teaching hospital. METHODS: A case control study on 363 participants, 121 cases and 242 controls, was conducted. Data was analyzed by STATA 14. Propensity score matching analysis was used to see causes. Level of significance of p value is ≤0.05. RESULTS: Females who reside in rural areas (AOR = 3.996; 95% CI: 2.011, 7.940) are at higher risk of acquiring uterine rupture. Females who had ANC follow-up (AOR = 0.315; 95% CI: 0.164, 0.606) and preterm gestational age (AOR = 0.135; 95% CI: 0.025, 0.725) are at lower risk of developing uterine rupture. Propensity score matching analysis shows that, from 100 participants who had uterine rupture, 88.4 females lost their fetus (ß = 0.884; 95% CI: 0.827, 0.942). From 100 females who develop uterine rupture, 9.1 died (ß = 0.091; 95% CI: 0.040, 0.142). From 100 females who develop uterine rupture, 97.5 developed additional obstetric complication (ß = 0.975; 95% CI: 0.947, 1.000). CONCLUSION: Residence, ANC follow-up, and gestational age are significant determinants of uterine rupture. Fetal loss, maternal death, and obstetric complications are significant bad outcomes of uterine rupture.