Magnitude and determinants of early initiation and exclusive breastfeeding at six weeks postpartum: evidence from the PMA Ethiopia longitudinal survey.

BACKGROUND: Early initiation and exclusive breastfeeding are crucial in preventing child morbidity and mortality. Despite the importance of these practices, rates of timely initiation of breastfeeding and exclusive breastfeeding remain suboptimal in many sub-Saharan countries, including Ethiopia. This paper aimed to estimate the prevalence and identify determinants of breastfeeding initiation within the first hour after birth and exclusive breastfeeding in Ethiopia. METHODS: Data from the Performance Monitoring for Action Ethiopia project, a national survey conducted from August 2019 to September 2020, were used. The analytical sample comprises 2564 postpartum women and their children; data reported at baseline during enrollment and six weeks postpartum were used in this analysis. A multi-level binary logistic regression model was employed to identify determinant factors linked with initiation breastfeeding and exclusive breastfeeding. RESULTS: Of the 2564 mothers, 77.8% of infants breastfed within the first hour of birth and 68.4% of women practiced exclusive breastfeeding at six weeks postpartum with significant variation across regions. In the multivariate analysis, mothers who had cesarean delivery were less likely to initiate early breastfeeding as compared to mothers with vaginal delivery (AOR 0.27; 95% CI 0.17, 0.41). The odds of early initiation of breastfeeding were higher for mothers whose baby cried immediately after birth (AOR 3.31; 95% CI 1.95, 5.62) and who had skilled assisted delivery (AOR 2.13; 95% CI 1.01, 4.48). Other factors that were significantly associated with early initiation of breastfeeding were obstetric complication(s), parity, immediate mother-to-baby skin-to-skin contact, immediate postnatal care and the region. Similarly, mothers whose babies had a good neonatal birth status (AOR 1.81; 95% CI 1.09, 2.99) were more likely to exclusively breastfeed their child at six weeks postpartum. CONCLUSIONS: Early initiation of breastfeeding and exclusive breastfeeding is sub-optimal in Ethiopia. Nutrition programmers should consider regional variations in designing intervention programs to enhance breastfeeding practices. Healthcare providers should give special attention to women at risk such as those giving birth through cesarean section and having obstetric complications during delivery.

Pregnancy coercion, correlates, and associated modern contraceptive use within a nationally representative sample of Ethiopian women.

Partner-perpetrated pregnancy coercion inhibits women's reproductive autonomy. However, few studies have quantified pregnancy coercion and its effects on women's health within low- and middle-income countries. Among a national sample of Ethiopian women, this study aimed to: (1) assess the prevalence of past-year pregnancy coercion and explore regional differences; (2) identify correlates; (3) examine the relationship between pregnancy coercion and modern contraceptive use. Analyses utilise cross-sectional data from Performance Monitoring for Action (PMA)-Ethiopia, a nationally representative sample of females aged 15-49 conducted from October to November 2019. Past-year pregnancy coercion was assessed via five items and analysed dichotomously and categorically for severity. Among women in need of contraception, bivariate and multivariable logistic regression examined associations between variables of interest, per aim, accounting for sampling weights and clustering by enumeration area. Approximately 20% of Ethiopian women reported past-year pregnancy coercion (11.4% less severe; 8.6% more severe), ranging from 16% in Benishangul-Gumuz to 35% in Dire Dawa. Increasing parity was associated with decreased odds of pregnancy coercion. Among women in need of contraception, experience of pregnancy coercion was associated with a 32% decrease in odds of modern contraceptive use (aOR = 0.68; 95% CI: 0.53-0.89); when disaggregated by severity, odds decreased for most severe pregnancy coercion (aOR = 0.59; 95% CI = 0.41-0.83). Results indicate that partner-perpetrated pregnancy coercion is prevalent across diverse regions of Ethiopia, and most severe forms could interrupt recent gains in contraceptive coverage and progress to sexual and reproductive health and rights. Providers must be aware of potential contraceptive interference and address coercive influences during contraceptive counselling.

Effect of the COVID-19 pandemic on health facility delivery in Ethiopia; results from PMA Ethiopia's longitudinal panel.

OBJECTIVES: To examine the effect of COVID-19 on health facility delivery in Ethiopia. DESIGN: We used longitudinal data with a pre-post exposure to the pandemic to assess change in facility delivery patterns nationally and by urban and rural strata. We conducted design-based multivariable multinomial logistic regression comparing home, lower-level facility, and hospital delivery with date of birth as a spline term, with a knot indicating births before and on/after April 8, 2020. SETTING: Six regions in Ethiopia, covering 91% of the population. PARTICIPANTS: Women were eligible to participate if they were currently pregnant or less than six weeks postpartum and were recontacted at six weeks, six months, and one year postpartum. 2,889 women were eligible and 2,855 enrolled. Data used in this paper come from the six-week interview, with a follow-up rate of 88.9% (2,537 women). RESULTS: In urban areas, women who delivered during the COVID-19 pandemic had a 77% reduced relative risk of delivering in a hospital relative to women who delivered prior to the pandemic (aRRR: 0.23, 95% CI: 0.07-0.71). There were no significant differences between the pre- and COVID-19 periods within rural strata where the majority of women deliver at home (55.6%). Overall, the effect was non-significant at a national level. Among women who delivered during the COVID-19 pandemic, 20.0% of urban women said COVID-19 affected where they delivered relative to 8.7% of rural women (p-value = 0.01). CONCLUSION: We found that delivery patterns in urban areas changed during the early months of the COVID-19 pandemic, but there was no evidence of large-scale declines of hospital delivery at the national level. Concerns about COVID-19 transmission in health facilities and ensuring lower-level facilities are equipped to address obstetric emergencies are critical to address. COVID-19 will likely slow progress towards increasing rates of institutional delivery in urban areas in Ethiopia.

A sexual and reproductive empowerment framework to explore volitional sex in sub-Saharan Africa.

Volitional sex is central to the sexual health and well-being of women and girls globally. To date, few studies have examined women's empowerment and its application to sexual health outcomes, including volitional sex. The aim of this study was to explore the relevance of a sexual and reproductive empowerment framework to volitional sex across four geographically and culturally diverse contexts in sub-Saharan Africa. Qualitative data were collected between July and August 2017 in four sites: Ethiopia, Nigeria (Anambra and Kano states) and Uganda. A total of 352 women aged 15-49 and 88 men aged 18 and older were interviewed through 120 in-depth interviews and 38 focus group discussions (n = 440 total participants). Results describe the substantial barriers restraining women's sexual choices, particularly norms that stigmatise women's requests for sex, even within marriage. Results further highlight women's internal sexual motivations, particularly related to the enjoyment of sex and the role of sex in strengthening partner relationships. Future empowerment research and measurement should focus not only on sexual constraints, but also integrate internal motivations, in order to fully understand the factors that shape women's sexual health outcomes.

Covert use of contraception in three sub-Saharan African countries: a qualitative exploration of motivations and challenges.

BACKGROUND: The balance between increasing men's participation in family planning and rights-based initiatives favoring women's empowerment is highlighted with the issue of covert use of contraception. While covert use has been documented in low- and middle-income countries as a way for women to obtain contraception in light of partner opposition, little is known about women's decision-making processes, actions, and potential consequences of discreet contraceptive use. We aimed to understand women's choices to use contraception covertly and the challenges they faced in concealing their use across three sub-Saharan African countries. METHODS: Women aged 15-49 and their male partners were purposively sampled from urban and rural sites in Ethiopia, Northern and Southern Nigeria, and Uganda for 120 in-depth interviews and 38 focus group discussions. Semi-structured interviews explored women's and girls' empowerment surrounding sex, childbearing, and contraception. Interviews were conducted in local languages, audio-recorded, and transcribed verbatim into English. Inductive thematic analysis was used to analyze data; covert use codes were reviewed and matrices were created based on themes and sub-themes. RESULTS: Findings comprised three thematic areas: the practice of covert contraceptive use and reasons for using covertly; challenges for women who use contraception covertly; and consequences of disclosure or being discovered. While some women initiated using contraception covertly due to tensions within relationships or to keep peace within the home due to known partner opposition, others did not consider family planning to be a male responsibility. Though covert use was commonly discussed, it was also socially sanctioned, and portrayed as an act of female disobedience that questioned the social order of patriarchy. Further challenges of using covertly included lack of financial and social support, and suspicions surrounding delayed fertility and contraceptive-related side effects. Repercussions comprised increased suspicion, threats, or violence, though some women reported improved couple communication with disclosure. CONCLUSIONS: Results indicate that while covert use of contraception is common, continued covert use is challenging, especially when side effects manifest. Covert use may further suggest women taking independent action, symbolizing some level of empowerment. Results underscore the importance of disentangling unique reasons for covert use and the severity of repercussions of disclosure.

Improving the demand for birth registration: a discrete choice experiment in Ethiopia.

INTRODUCTION: Birth registration remains limited in most low and middle-income countries. We investigated which characteristics of birth registration facilities might determine caregivers' decisions to register children in Ethiopia. METHODS: We conducted a discrete choice experiment in randomly selected households in Addis Ababa and the Southern Nations, Nationalities, and People's Region. We interviewed caregivers of children 0-5 years old. We asked participants to make eight choices between pairs of hypothetical registration facilities. These facilities were characterised by six attributes selected through a literature review and consultations with local stakeholders. Levels of these attributes were assigned at random using a fractional design. We analysed the choice data using mixed logit models that account for heterogeneity in preferences across respondents. We calculated respondents' willingness to pay to access registration facilities with specific attributes. We analysed all data separately by place of residence (urban vs rural). RESULTS: Seven hundred and five respondents made 5614 choices. They exhibited preferences for registration facilities that charged lower fees for birth certificates, that required shorter waiting time to complete procedures and that were located closer to their residence. Respondents preferred registration facilities that were open on weekends, and where they could complete procedures in a single visit. In urban areas, respondents also favoured registration facilities that remained open for extended hours on weekdays, and where the presence of only one of the parents was required for registration. There was significant heterogeneity between respondents in the utility derived from several attributes of registration facilities. Willingness to pay for access to registration facilities with particular attributes was larger in urban than rural areas. CONCLUSION: In these regions of Ethiopia, changes to the operating schedule of registration facilities and to application procedures might help improve registration rates. Discrete choice experiments can help orient initiatives aimed at improving birth registration.

Correction: Does proximity of women to facilities with better choice of contraceptives affect their contraceptive utilization in rural Ethiopia?

[This corrects the article DOI: 10.1371/journal.pone.0187311.].

Does proximity of women to facilities with better choice of contraceptives affect their contraceptive utilization in rural Ethiopia?

BACKGROUND: There is limited evidence of the linkage between contraceptive use, the range of methods available and level of contraceptive stocks at health facilities and distance to facility in developing countries. The present analysis aims at examining the influence of contraceptive method availability and distance to the nearby facilities on modern contraceptive utilization among married women in rural areas in Ethiopia using geo-referenced data. METHODS: We used data from the first round of surveys of the Performance Monitoring & Accountability 2020 project in Ethiopia (PMA2020/Ethiopia-2014). The survey was conducted in a sample of 200 enumeration areas (EAs) where for each EA, 35 households and up to 3 public or private health service delivery points (SDPs) were selected. The main outcome variable was individual use of a contraceptive method for married women in rural Ethiopia. Correlates of interest include distance to nearby health facilities, range of contraceptives available in facilities, household wealth index, and the woman's educational status, age, and parity and whether she recently visited a health facility. This analysis primarily focuses on stock provision at public SDPs. RESULTS: Overall complete information was collected from 1763 married rural women ages 15-49 years and 198 SDPs in rural areas (97.1% public). Most rural women (93.9%) live within 5 kilometers of their nearest health post while a much lower proportion (52.2%) live within the same distance to the nearest health centers and hospital (0.8%), respectively. The main sources of modern contraceptive methods for married rural women were health posts (48.8%) and health centers (39.0%). The mean number of the types of contraceptive methods offered by hospitals, health centers and health posts was 6.2, 5.4 and 3.7 respectively. Modern contraceptive use (mCPR) among rural married women was 27.3% (95% CI: 25.3, 29.5). The percentage of rural married women who use modern contraceptives decreased as distance from the nearest SDP increased; 41.2%, 27.5%, 22.0%, and 22.6% of women living less than 2 kilometers, 2 to 3.9kilometers, 4 to 5.9 kilometers and 6 or more kilometers, respectively (p-value<0.01). Additionally, women who live close to facilities that offer a wider range of contraceptive methods were significantly more likely to use modern contraceptives. The mCPR ranged from 42.3% among women who live within 2 kilometers of facilities offering 3 or more methods to 22.5% among women living more than 6 kilometers away from the nearest facility with the same number (3 or more methods) available after adjusting for observed covariates. CONCLUSIONS: Although the majority of the Ethiopian population lives within a relatively close distance to lower level facilities (health posts), the number and range of methods available (method choice) and proximity are independently associated with contraceptive utilization. By demonstrating the extent to which objective measures of distance (of relatively small magnitude) explain variation in contraceptive use among rural women, the study fills an important planning gap for family planning programs operating in resource limited settings.