Pre-referral management of preeclampsia with severity features in a low-income country-characteristics and challenges in a Sub-Saharan setting: a mixed method study.

BACKGROUND: Preeclampsia continues to be a major cause of maternal and perinatal mortality and morbidity globally. Although pre-referral treatment constitutes a bigger part of the management package for preeclampsia with severity features in low-income settings, little is known regarding the characteristics and challenges of preeclampsia pre-referral and referral management in the Sub-Saharan setting. OBJECTIVE: To determine the characteristics and challenges of pre-referral and referral management of preeclampsia with severity features. STUDY DESIGN: We conducted a mixed method study on the pre-referral management of pregnant women complicated by preeclampsia with severity features in Ethiopia. We prospectively collected data on clinical characteristics, management outcomes, and pre-referral characteristics of pregnant women who are complicated by preeclampsia with severity features. Data were collected using a structured questionnaire. For the qualitative part of our study, we conducted 20-30 minutes of semistructured, qualitative, face-to-face, in-depth interviews with 14 health professionals. Quantitative data were analyzed using SPSS (version 23), and simple descriptive statistics were employed. We used thematic analysis on Open Code 4.03 software to analyze the qualitative data. RESULTS: A total of 261 pregnant women who had preeclampsia with severity features were included in the study, and 14 care providers were interviewed about existing challenges with pre-referral management for patients with preeclampsia with severity features. The mean systolic and diastolic blood pressures were 154.3 mm Hg and 100.3 mm Hg, respectively. The total perinatal mortality was 6.5% (17/261). Three of 261 mothers (1.1%) were complicated by intracranial hemorrhage, and other 1.1% (3/261) of other women developed pulmonary edema. Out of 261 patients, only 41 patients (15.7%) received magnesium sulfate before referral. Similarly, antihypertensive medication was given only to 35 of 261 patients (13.4%) pre-referral. Eight of 261 mothers convulsed (3.1%) during referral. Two of 261 mothers (0.8%) developed pulmonary edema when they arrived at recipient health institutions after referral. Similarly, another 2 of 261 (0.8%) women developed disseminated intravascular coagulation by the time of arrival from the referring health institution. On the basis of qualitative data analysis, 3 overarching themes were recognized: (1) challenges related to patient and family resistance, (2) Challenges related to healthcare providers' knowledge, skill, and confidence, and (3) health system-related challenges. Low use of magnesium sulfate and antihypertensive drugs, patient misperceptions regarding reasons for referral, providers' lack of knowledge on the pre-referral management, inadequate communication between referring and recipient health institutions, and nonexistence of uniform preeclampsia pre-referral and referral management protocols among the referring institutions were the identified gaps. CONCLUSION: We found a significant gap in pre-referral management for patients with preeclampsia with severity features. Preeclampsia management policy reforms should include the introduction of adequate patient counseling platforms, increasing community awareness creation, providing in-service training on pre-referral management of preeclampsia for health personnel, ensuring constant availability of anticonvulsant and antihypertensive drugs and uniform implementation of preeclampsia pre-referral management protocols across health institutions.

Can mid-level providers manage medical abortion after 12 weeks' gestation as safely and effectively as physicians? A non-inferiority, randomized controlled trial in Addis Ababa, Ethiopia.

OBJECTIVE: To determine whether clinical outcomes among clients undergoing medical abortion after 12 weeks' gestation differ by provider cadre. METHODS: Randomized controlled trial conducted among eligible clients seeking abortion between 13 and 20 weeks' gestation. Participants seeking in-facility abortion were randomized to receive care from a mid-level provider (nurse/midwife) or physician. The primary outcome was median time to expulsion with non-inferiority margin of -1.5 h between provider groups. Quantile median regression models assessed non-inferiority. Secondary outcomes included retained placenta, complications, and patient acceptability. RESULTS: After randomization and eligibility assessment by the provider, 171 women participated in the study: 81 in the physician group and 90 in the mid-level provider group. Their average age was 24 years, the mean gestational age was 16 weeks, and 65% were nulliparous in both groups. The median time to expulsion did not differ significantly, being 8.1 h for the mid-level group and 6.6 h for the physician group. The adjusted median difference was 0.8 h (95% confidence interval [CI] -1.15 to 2.66), within the non-inferiority margin. Retained placenta occurred similarly: 30.0% (n = 24) of the physician group and 20.5% (n = 18) of the mid-level provider group (adjusted risk difference [ARD] 7.6%, 95% CI -2.81 to 18.06). Complications occurred in 7% of cases, including 5.0% (n = 4) of patients in the physician group and 8.9% (n = 8) in the mid-level provider group (ARD -4.7%, 95% CI -12.43 to 3.12). Patient acceptability did not differ by group. CONCLUSIONS: Training mid-level providers to provide abortion services after 12 weeks' gestation independently of physicians is feasible and may result in comparable clinical outcomes.

"I was waiting for my period": Understanding pregnancy recognition among adolescents seeking abortions in Ethiopia, Malawi, and Zambia.

OBJECTIVES: For a person seeking an abortion, the ability to recognize a pregnancy is a critical first step. Pregnancy recognition is complex and shaped by numerous factors. This paper explores the experiences of pregnancy recognition among adolescents in Ethiopia, Malawi, and Zambia. STUDY DESIGN: The final sample included 313 adolescents aged 10 to 19 who had sought abortion-related care at urban public facilities in Ethiopia (N = 99), Malawi (N = 104), and Zambia (N = 110). Researchers collected mixed-method data on how adolescents came to recognize that they were pregnant and thematically analyzed qualitative data alongside descriptive statistics from quantitative data. RESULTS: Most adolescents reported that their main mode of recognizing a pregnancy was medical pregnancy tests or late menstruation. Reasons for not recognizing a pregnancy included irregular menses or recent menarche and attribution of signs and symptoms to other medical conditions. Psychological barriers to pregnancy recognition were important, including the refusal to accept a pregnancy and denial of a pregnancy. Timing of recognition shaped the abortion care available for adolescents and the affordability of care. For some adolescents, their capacity to recognize their pregnancy led to involuntary or voluntary disclosure, which decreased their reproductive autonomy. CONCLUSIONS: Adolescent experiences of pregnancy recognition complement existing evidence, illustrating critical barriers across age and context. Interrogating pregnancy recognition among adolescents exposed the critical implications for the availability, accessibility, affordability, and autonomy of their abortion trajectory. IMPLICATIONS: Pregnancy recognition is complex and can influence adolescents' ability to exercise their reproductive rights and access abortion care of their choosing. Programmes to improve awareness of the signs of a pregnancy, increasing the provision of affordable and accessible pregnancy testing and further research on pregnancy recognition are necessary to support adolescents' reproductive autonomy.

Adherence to Antiretroviral Medications Among People Living With HIV in the Era of COVID-19 in Central Ethiopia and Perceived Impact of the Pandemic.

AIM: This study assessed the level of adherence to antiretroviral drugs and the associated factors among clients who have a follow-up at public health facilities in central Ethiopia. METHOD: A multi-site cross-sectional study was conducted from August 1-30, 2020 at seven public health institutions. A systematic random sampling method was used to recruit 385 participants. Data was collected using a structured interviewer-administered questionnaire. Analysis was done using descriptive statistics, and binary logistic regression model. The OR with its 95% C.I was employed to present analytic outputs. Statistical significance for the multivariable model was considered at p ≤ 0.05. RESULTS: Of the 371 participants, the majority were females (233, 62.8%), attended health centers (215, 58.0%), and were married (173, 46.6%). Eighty-nine (89, 24.0%) of the participants have at least one comorbidity. About 72 (19.0%) and 50 (13.5%) of the respondents stated that the COVID-19 has posed challenges on their follow-ups and availability of medications respectively. Nearly a half of the people living with HIV and comorbid T2DM or hypertension (29, 48.0%) reported that they had encountered an increase in the price of medications compared to the pre-COVID-19 times. About half of the respondents in the study setting have perfect adherence to antiretroviral therapy (ART) (200, 54.0%). Basic education (aOR = 3.02: 95% CI: 1.57-5.80), marriage (aOR = 2.27: 95% CI: 1.24-4.15), attendance to a health center (aOR = 0.59: 95% CI: 0.36-0.98) and sleep disturbance (aOR = 0.47: 95% CI: 0.26-0.84) showed a statistically significant association with adherence to ART. CONCLUSION: About half of the respondents in the study settings have perfect adherence to their ART medications. As multiple factors interplay in the success rate of adherence to ART, stakeholders should place and strengthen practices, such as active follow-up and tracing of cases, ensuring medication affordability (access and low pricing), and psycho-social support to patients.

Health-Related Quality of Life of Patients with Type 2 Diabetes Mellitus and Hypertension in Addis Ababa, Ethiopia.

Background: The aim of this study was to assess the health-related quality of life of patients with T2DM and hypertension attending public health facilities in Addis Ababa, Ethiopia. Methods: A cross-sectional study was conducted from 1st through 30th August 2020 at the selected institutions. Health facilities were chosen purposively based on patient load. Participants were drawn after proportional to size allocation. A translated EQ-5D-3L, and EQ-VAS instrument was used to collect the data. Analysis was done using SPSS v.26.0. Both parametric and non-parametric models were applied in the analysis. Results: Of the 409 participants included, the majority were in the age group of 46-60 (36.0%), females (56.0%), from hospitals (54.8%), jobless (25.4%), and married (63.3%). Over two-thirds of the patients reported no problems with self-care, usual activity, and depression/anxiety. All dimensions showed an increasing proportion of moderate to severe problems in the age group beyond 45. Facility type, comorbid condition and age showed a statistically significant score difference for QoL. The overall prevalence of any problem was 59.0%. Education level, visit to a health center, and marriage showed lower odds of affected HRQoL whereas, lower monthly income and presence of comorbidities were opposite. Conclusion: HRQoL of patients in the study settings was suboptimal and below the general population. Attributes, such as education, facility type, marital status, income level, and comorbid status have a statistically significant association with HRQoL. Arrangement of a safe and quality health services is paramount, especially, during the COVID-19 pandemic.

Awareness of diagnosis, treatment plan and prognosis among patients attending public hospitals and health centers in Addis Ababa, Ethiopia.

INTRODUCTION: Providing patient-centered care is one of the key focus areas of the Ethiopian Health Service Transformation Plan. To this end, improving health literacy of the community is critical. However, there is limited evidence about the health literacy of Ethiopians, especially among those who visit health facilities. OBJECTIVE: The aim of this study was to examine awareness of diagnosis, treatment plan and prognosis among patients at the time of their exit from public hospitals and health centers. METHODS: A cross-sectional study was conducted among 627 patients in two public hospitals and selected health centers in Addis Ababa, using a systematic random sampling technique from inpatient and outpatient departments (OPD). A total of 579 study participants had complete data and were included in this analysis. A structured, pre-tested and interview-administered questionnaire was used to collect data. We used proportions to describe the findings and logistic regression analyses to assess factors associated with awareness of diagnosis, treatment plan and prognosis. RESULT: About three-fifths (61.9%) and 52.8% of the study participants knew correctly their diagnosis and treatment plan respectively. More than two-thirds, 68.4%, said that they knew about the prognosis of their illness. However, only 21 (3.6%) patient medical records had information on prognosis. Gynecologic patients had significantly lower awareness about their diagnosis and treatment plan as compared to those from a general outpatient department. Emergency patients had significantly lower awareness of their treatment plan (OR = 0.27; 95% CI: 0.11,0.68) and prognosis (OR = 0.21; 95% CI: 0.09,0.50) than new OPD patients. Patients who indicated they had a good experience at their clinical assessment had significantly lower awareness of their prognosis (OR = 0.25; 95% CI: 0.08, 0.81). CONCLUSION: A significant proportion of patients didn't know their correct diagnosis, treatment plan and prognosis. This was more pronounced among gynecologic and emergency patients. More efforts are needed to strengthen patient-provider interaction.

Providers' View on the First Kidney Transplantation Center in Ethiopia: Experience From Past to Present.

INTRODUCTION: Transplantation is the optimal management for patients with end-stage renal disease. In Ethiopia, the first national kidney transplantation center was opened at St. Paul's Hospital Millennium Medical College in September 2015. The aim of this study was to explore providers' views and experiences of the past to present at this center. METHODS: A qualitative study design was employed from 1st November to 15th December, 2019. To ensure that appropriate informants would provide rich study data, 8 health care providers and top management members were purposefully chosen for in-depth interviews. A maximum variation sampling method was considered to include a representative sample of informants. Interviews were digitally audio-recorded, and transcribed verbatim. Transcribed data was coded and analyzed using Qualitative Data Analysis (QDA) Minor Lite software and Microsoft-Excel. RESULT: The participants (5 males and 3 females) approached were from different departments of the renal transplant center, and the main hospital. Eight main themes and 18 sub-themes were generated initially from all interviews totaling to 109 index codes. Further evaluation and recoding retained 5 main themes, and 14 sub-themes. The main themes are; challenges experienced during and after launching the center, commitment, sympathy and satisfaction, outcomes of renal transplant, actions to improve the quality of service, and how the transplant center should operate. Providers claim that they discharge their responsibilities through proper commitment and compassion, paying no attention to incentive packages. They also explained that renal transplantation would have all the outcomes related to economic, humanistic and clinical facets. CONCLUSION AND RECOMMENDATION: A multitude of challenges were faced during and after the establishment of the first renal transplant center in Ethiopia. Providers discharge their responsibility through a proper compassion for patients. Concerned stakeholders should actively collaborate to improve the quality of renal transplant services in the center.

Magnitude and associated factors of poor medication adherence among diabetic and hypertensive patients visiting public health facilities in Ethiopia during the COVID-19 pandemic.

OBJECTIVE: This study aims to assess the magnitude and associated factors of poor medication adherence among diabetic and hypertensive patients visiting public health facilities in Addis Ababa, Ethiopia during the COVID-19 pandemic. METHODS: A multi-site cross-sectional design was conducted from 1st through 30th of August 2020 at public health facilities of the study area. Adult outpatients with T2DM and hypertension visiting hospitals and health centers were included in the study. A proportion to size allocation method was used to determine the required sample size per facility. Data was collected using the 8-item Morisky medication adherence scale. Descriptive statistics and binary logistic regression were used to analyze data. A 95% confidence interval and p≤0.05 statistical significance was considered to determine factors associated with poor medication adherence. RESULTS: A total of 409 patients were included in the present study. About 57% of the patients reported that the COVID-19 pandemic has posed negative impacts on either of their follow-up visits, availability of medications, or affordability of prices. And, 21% have reported that they have been affected in all aspects. The overall magnitude of poor medication adherence was 72%. Patients with extreme poverty were more likely to have good medication adherence (AOR: 0.59; 95%C.I: 0.36-0.97), whereas attendance to a health center (AOR: 1.71; 95%C.I: 1.02-2.85), presence of comorbidity (AOR: 2.05; 95%C.I: 1.13-3.71), and current substance use history (AOR: 11.57; 95%C.I: 1.52-88.05) predicted high odds of poor adherence. CONCLUSION: Over a three-fourth of the patients, in the study setting, have poor adherence to their anti-diabetic and antihypertensive medications. Health facility type, income level, comorbidity, and current substance use history showed a statistically significant association with poor adherence to medication. Stakeholders should set alternative strategies as perceived impacts of the COVID-19 pandemic on medication adherence are high in the study area.