In uncharted territory "together each achieves more": a United Nations interagency collaboration for continuity of maternal and newborn health services during the coronavirus pandemic in the Eastern and Southern Africa region.

The frangible collaboration between three United Nations agencies (UNICEF, UNFPA and WHO) in the Eastern and Southern Africa Region was strengthened by the outbreak of the coronavirus pandemic. The aim was to combine existing resources and expertise to support countries to respond to the pandemic more effectively and efficiently regarding the provision of maternal and newborn health services. Three kinds of activities were conducted: 15 webinars on a variety of topics and issues impacted by the pandemic; virtual training on maternal and perinatal death surveillance and response as well as on quality improvement; and the development of online e-learning modules for continuous professional development. Key dimensions of the collaboration included: a common vision; commitment to the process; dialogue; building relationships and trust; communication and information sharing; sharing of technical and financial resources and expertise; mobilization of additional resources; celebration of intermediate outcomes; facilitative leadership; and institutional design. Start-up lessons revolved around shared risk taking, while retaining agency autonomy. Collaboration lessons included forming a "united front", harnessing technology to accelerate results, and mitigating adverse structural and contextual factors. There are widespread perceptions that collaborative initiatives tend to yield minimum results in terms of increased efficiency or effectiveness. This particular collaborative effort demonstrated elements of feasibility, value addition, synergy, cost effectiveness and demonstrable results where UN agencies delivered as one. The emergency in healthcare as a ripple effect of the coronavirus pandemic has caused a rethink of collaboration models and levels of engagement.

Measuring the spatial heterogeneity on the reduction of vaginal fistula burden in Ethiopia between 2005 and 2016.

Vaginal fistula is a shattering maternal complication characterized by an anomalous opening between the bladder and/or rectum and vagina resulting in continuous leakage of urine or stool. Although prevalent in Ethiopia, its magnitude and distribution is not well studied. We used statistical mapping models using 2005 and 2016 Ethiopia Demographic Health Surveys data combined with a suite of potential risk factors to estimate the burden of vaginal fistula among women of childbearing age. The estimated number of women of childbearing age with lifetime and untreated vaginal fistula in 2016 were 72,533 (95% CI 38,235-124,103) and 31,961 (95% CI 11,596-70,309) respectively. These figures show reduction from the 2005 estimates: 98,098 (95% CI 49,819-170,737) lifetime and 59,114 (95% CI 26,580-118,158) untreated cases of vaginal fistula. The number of districts having more than 200 untreated cases declined drastically from 54 in 2005 to 6 in 2016. Our results show a significant subnational variation in the burden of vaginal fistula. Overall, between 2005 and 2016 there was substantial reduction in the prevalence of vaginal fistula in Ethiopia. Our results help guide local level tracking, planning, spatial targeting of resources and implementation of interventions against vaginal fistula.

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.

Trends in contraceptive use and distribution of births with demographic risk factors in Ethiopia: a sub-national analysis.

BACKGROUND: Evidence shows that family planning contributes to the decline in child mortality by decreasing the proportions of births that are considered high risk. The main objective of the present analysis was to examine the trends in use of modern contraceptives and their relationship with total fertility rate (TFR) and distribution of births by demographic risk factors as defined by mother's age, birth interval, and birth order at the sub-national level in Ethiopia. DESIGN: Analyses used data from three Demographic and Health Surveys in Ethiopia (2000, 2005, and 2011), which are nationally representative data collected through questionnaire-based interviews from women 15-49 using a stratified, two-stage cluster sampling. First, we examined the trends of and relationship between TFR (in the 3 years before each survey) and modern contraceptive use among currently married women in all administrative regions over the time period 2000-2011 using linear regression analysis. We also examined the relationship between birth risks and under-five mortality using the no-risk group as a reference. Finally, multiple logistic regression analysis was performed to estimate the relationship between the effect of being a resident in one of the regions and having an avoidable birth risk (which includes births to mothers younger than 18 and older than 34 years, birth interval of less than 24 months and birth order higher than third) after adjusting for select covariates including wealth, educational status, residence, religion and exposure to family planning information. RESULTS: Sub-national-level regression analysis showed an inverse relationship between modern contraceptive use among married women and the TFR, with an average decrease of TFR by one child per woman associated with a 13 percentage point increase in modern contraceptive use between 2000 and 2011. A high percentage of births in Ethiopia (62%) fall in one of the risk categories (excluding first births), with wide regional variation from 55% in Gambela to 72% in the Somali region. The multivariate analysis showed women living in the Somali, Afar and Benishangul-Gumuz regions had significantly higher odds of having avoidable birth risk compared to those in Addis Ababa after controlling for observed covariates. The trend analysis showed there was a significant drop in the proportion of births from women above 34 years between 2000 and 2011. There was no significant decline in births to women less than 18 years between 2000 and 2011. CONCLUSIONS: A majority of births in Ethiopia fall in one of the risk categories, with substantial region-to-region variation in the percentage of births with avoidable risk factors, Somali and Afar having the highest burden. The analysis indicated that births in the three regions had significantly higher odds of having one of the avoidable risk factors compared to Addis Ababa, and we suggest family planning programmes need to identify differentials of modern contraceptive use at the sub-national level in order to better address coverage and equity issues.

Towards universal health coverage for reproductive health services in Ethiopia: two policy recommendations.

Reproductive health services are crucial for maternal and child health, but universal health coverage is still not within reach in most societies. Ethiopia's goal of universal health coverage promises access to all necessary services for everyone while providing protection against financial risk. When moving towards universal health coverage, health plans and policies require contextualized knowledge about baseline indicators and their distributions. To understand more about the factors that explain coverage, we study the relationship between socioeconomic and geographic factors and the use of reproductive health services in Ethiopia, and further explore inequalities in reproductive health coverage. Based on these findings, we discuss the normative implications of these findings for health policy. Using population-level data from the Ethiopian Demographic and Health Survey (2011) in a multivariate logistic model, we find that family planning and use of antenatal care are associated with higher wealth, higher education and being employed. Skilled attendance at birth is associated with higher wealth, higher education, and urban location. There is large variation between Addis Ababa (the capital) and other administrative regions. Concentration indices show substantial inequalities in the use of reproductive health services. Decomposition of the concentration indices indicates that difference in wealth is the most important explanatory factor for inequality in reproductive health coverage, but other factors, such as urban setting and previous health care use, are also associated with inequalities. When aiming for universal health coverage, this study shows that different socioeconomic factors as well as health-sector factors should be addressed. Our study re-confirms the importance of a broader approach to reproductive health, and in particular the importance of inequality in wealth and geography. Poor, non-educated, non-employed women in rural areas are multidimensionally worse off. The needs of these women should be addressed through elimination of out-of-pocket costs and revision of the formula for resource allocation between regions as Ethiopia moves towards universal health coverage.

Distance to emergency obstetric services and early neonatal mortality in Ethiopia.

OBJECTIVES: To assess the effect of distance to emergency obstetric and newborn care (EmONC) services on early neonatal mortality in rural Ethiopia and examine whether proximity to services contributes to socio-economic inequalities in early neonatal mortality. METHODS: We linked data from the 2011 Ethiopian Demographic and Health Survey with facility data from the 2008 Ethiopian National EmONC Needs Assessment based on geographical coordinates collected in both surveys. Health facilities were classified based on the performance of nine EmONC signal functions (e.g. neonatal resuscitation, Caesarean section). We used multivariable logistic regression to assess the relationship between distance to services and early neonatal mortality. A decomposition approach was used to quantify the relative contributions of distance to EmONC services and other determinants to overall and socio-economic inequality in early neonatal mortality. RESULTS: In general, closer proximity to EmONC services and higher level of care were associated with lower early neonatal mortality. Living more than 80 km from the nearest comprehensive EmONC facility able to perform all nine signal functions compared to living within 10 km was associated with an increase of 14.4 early neonatal deaths per 1000 live births (95% CI: 0.1, 28.7). Closer proximity to a substandard EmONC facility compared with no facility was not associated with lower early neonatal mortality. Distance to EmONC services was an important determinant of early neonatal mortality, although it did not make a significant contribution to explaining socio-economic inequality. CONCLUSIONS: Our results suggest that recent initiatives by the Ethiopian government to improve geographical access to EmONC services have the potential to reduce early neonatal mortality but may not affect inequalities.

Using a GIS to model interventions to strengthen the emergency referral system for maternal and newborn health in Ethiopia.

OBJECTIVES: To show how GIS can be used by health planners to make informed decisions about interventions to increase access to emergency services. METHODS: A combination of data sources, including the 2008 national Ethiopian baseline assessment for emergency obstetric and newborn care that covered 797 geo-coded health facilities, LandScan population data, and road network data, were used to model referral networks and catchment areas across 2 regions of Ethiopia. STATA and ArcGIS software extensions were used to model different scenarios for strengthening the referral system, defined by the structural inputs of transportation and communication, and upgrading facilities, to compare the increase in access to referral facilities. RESULTS: Approximately 70% of the population of Tigray and Amhara regions is served by facilities that are within a 2-hour transfer time to a hospital with obstetric surgery. By adding vehicles and communication capability, this percentage increased to 83%. In a second scenario, upgrading 7 strategically located facilities changed the configuration of the referral networks, and the percentage increased to 80%. By combining the 2 strategies, 90% of the population would be served by midlevel facilities within 2 hours of obstetric surgery. The mean travel time from midlevel facilities to surgical facilities would be reduced from 121 to 64 minutes in the scenario combining the 2 interventions. CONCLUSIONS: GIS mapping and modeling enable spatial and temporal analyses critical to understanding the population's access to health services and the emergency referral system. The provision of vehicles and communication and the upgrading of health centers to first level referral hospitals are short- and medium-term strategies that can rapidly increase access to lifesaving services.

Ethiopia's assessment of emergency obstetric and newborn care: setting the gold standard for national facility-based assessments.

OBJECTIVE: To describe the methods used to implement Ethiopia's 2008 emergency obstetric and newborn care services (EmONC) assessment; highlight how the collaborative process contributed to immediate integration of results into national and subnational planning; and explain how the experience informed the development of a set of tools providing best practices and guidelines for other countries conducting similar assessments. METHODS: A team of maternal and newborn health experts from the Federal Ministry of Health (FMOH), the United Nations Children's Fund (UNICEF), the World Health Organization (WHO), and the United Nations Population Fund (UNFPA), together with representatives from the Ethiopian Society of Obstetricians and Gynecologists, provided technical guidance for the 18-month process and facilitated demand for and use of the assessment results. Eighty-four trained data collectors administered 9 data collection modules in 806 public and private facilities. Field work and data were managed by a private firm who, together with the core team, implemented a multi-layered plan for data quality. Columbia University's Averting Maternal Death and Disability Program provided technical assistance. RESULTS: Results were published in national and regional reports and in 1-page facility factsheets informing subnational planning activities. Assessment results-which have been published in journal articles-informed water infrastructure improvements, efforts to expand access to magnesium sulfate, and FMOH and UN planning documents. The assessment also established a permanent database for future monitoring of the health system, including geographic locations of surveyed facilities. CONCLUSION: Ethiopia's assessment was successful largely because of active local leadership, a collaborative process, ample financial and technical support, and rapid integration of results into health system planning.

Readiness of organizations for change, motivation and conflict-handling intentions: senior nursing students' perceptions.

This study examined the perceptions of 62 senior nursing students of the readiness of Jordanian organizations for change, students' motivators and their conflict-handling intentions. Such concepts should be taught at Schools of Nursing in order to prepare the students as nurses in the near future. It is found that the course of "Nursing Leadership and Management" has positive influence on students' understanding of the studied concepts. This descriptive study was conducted in seven hospitals. Grossman and Valiga's (2000) [Grossman, S., Valiga, T.M., 2000. The New Leadership Challenge: Creating the Future of Nursing. F.A. Davis, Philadelphia, pp. 147-148.] instrument was used to measure the readiness of organizations for change. As they progress in the course, the students' perceptions about the organizational readiness to change increased; the students "somehow" perceived that the Jordanian organizations were ready to change. The students were asked what motivates and they were asked about their conflict-handling techniques. Senior nursing students reported that private hospitals were better than governmental hospitals in their readiness for change. In general, male students perceived the readiness of organizations for change more positively than female students. The students were mainly motivated by "achievement" and used "collaboration" as a primary conflict-handling technique. Further studies are needed to explore in-depth the concept of the readiness of organizations for change. Achievement is a strong motivator that should be encouraged among students. Conflict-handling techniques in general and collaboration in particular should be taught for nursing students as these techniques will influence their future professional lives.

Making pregnancy safer initiative--program impact in selected pilot areas.

OBJECTIVE: This paper highlights program evaluation carried out on Making Pregnancy Safer Program interventions implemented by FHD in partnership with WHO, UNICEF, UNFPA, SIDA Sweden, the World bank and European Commission to increase availability of Emergency Obstetric Care Services in four pilot regions. METHOD: A participatory evaluation design was employed that included FMoH, RHB and other key partners. The qualitative approach examined client and community perception, provider's perspectives and program manager's views at different levels with regard to service provision, quality of care, service utilization and the impact of the MPS strategy. The quantitative aspect assessed met and unmet needs, service utilization and quality of service. RESULTS: Evaluation shown positive trend in process indicators of maternal health service utilization. Staff who received training in Emergency Obstetric Care are better off in both skill and knowledge acquisition. Majority of facilities had basic resources and functions for Emergency Obstetrics care. However, infrastructure deficiencies such as absence of waiting area, lack of privacy for clients, lack of toilets and water, shortage of life saving drugs, lack of context specific IEC materials were observed. At the community level, the main reason for dissatisfaction with health facility services was poor service provider attitude. CONCLUSION: MPS established a strong foundation to build stronger, better quality of emergency obstetrics and neonatal care that are used by those who needed it. It is time to consolidate and sustain improvements and vigorously support Regional Health Bureaus to ensure quality emergency obstetrics and neonatal care can be made available for all pregnant women, and progress toward the Millennium Development Goals can be achieved.