Psychometric properties of a modified health belief model for cervical cancer and visual inspection with acetic acid among healthcare professionals in Ethiopia.

PURPOSE: Evidence supports that the Health Belief Model (HBM) can explain and predicts certain health behaviors, including participation in cervical cancer (CC) screening. The purpose of this study was to evaluate the psychometric properties of a modified HBM for CC and visual inspection with acetic acid (VIA) in female healthcare professionals in Addis Ababa, Ethiopia, 2020. METHODS: Psychometric properties related to CC and VIA were tested using 42-item modified HBM self-administered questionnaire and a cross-sectional study design with simple random sampling. Kaiser-Meyer-Olkin and Bartlett's sphericity test indicated that data sampling adequacy for exploratory factor analysis was 0.792 (χ2 = 3189.95, df = 351, p < .001). Items with cross-loading and factor loadings ≥ 0.5 were retained. Confirmatory factor analysis (CFA) was conducted to determine model fit. RESULTS: The final analysis included 194 women, (mean age 30±4.34). Twelve items with ≤ 0.5 were removed and 30 retained items loaded into 6 factors; (benefits of VIA, perceived seriousness of CC, barrier (fear of negative outcome), self-efficacy, susceptibility to CC, and barriers (health system delivery)) explained 65% of the total variance. Cronbach's alpha for the total instrument was 0.8 and reliability for the 6 subscales was 0.76-0.92. Composite reliability and average variance extracted indicated good internal consistency and convergent validity. CFA identified 6 additional items to be removed with high residual covariance. The final 24 items of the modified HBM had an acceptable model fit (goodness-of-fit index (GFI) = 0.861, adjusted GFI = 0.823, comparative fit index = 0.937, root mean square error of approximation = 0.059). CONCLUSION: The modified HBM for CC and VIA with 24 items had adequate psychometric properties and may be used by Ethiopian healthcare professionals for research or clinical purposes. To support external validity the updated 24 items tool is suggested for application in further study in different populations in Ethiopia.

Mediating effects of women's empowerment on dietary diversity during pregnancy in Central West Ethiopia: A structural equation modelling.

BACKGROUND: Considerable proportions of pregnant women consume inadequately diversified diets in Ethiopia. On the other hand, women's empowerment is identified as a means of achieving maternal nutrition improvement. However, evidence on the relationship between multiple dimensions of women's empowerment and dietary diversity during pregnancy is limited in Ethiopia. OBJECTIVE: This study aimed to assess the mediating effects of women's empowerment in the pathway between women's education and dietary diversity during pregnancy in West Shewa zone, Ethiopia. METHODS: A health facility-based cross-sectional study was conducted among 1,383 pregnant women in 2021. Dietary diversity was measured using the minimum dietary diversity for women (MDD-W) tool. Exploratory and confirmatory factor analyses were employed to identify and validate women's empowerment dimensions. Structural equation modelling (SEM) was used to examine the pathways linking pregnant women's education and empowerment to dietary diversity during pregnancy. RESULTS: From the latent dimensions of women's empowerment produced by factor analyses, pregnant women's education was directly associated with household decision-making power, psychological and time dimensions. In turn, household decision-making power, psychological and time dimensions were associated with dietary diversity during pregnancy. The direct relationship between pregnant women's education and dietary diversity was insignificant, but the total indirect effect and total effect were significant. Household decision-making power, psychological and time dimensions were significant mediators in the relationship between pregnant women's education and dietary diversity. However, economic dimension was related to neither pregnant women's education nor dietary diversity. CONCLUSION: This study highlights pregnant women with better education are more likely to be empowered in household decision-making, psychological and time dimensions; and those empowered pregnant women are more likely to consume more diverse diets, suggesting women's access to higher education could have a positive indirect effect on consumption of more diverse diets during pregnancy by empowering women in the study area.

Predicting nutritional status during pregnancy by women's empowerment in West Shewa Zone, Ethiopia.

Background: Considerable proportions of pregnant women are affected by poor nutrition outcomes in Ethiopia. Women's empowerment, on the other hand, is highly recognized as a means to achieve better maternal nutrition outcomes. However, the role of pregnant women's empowerment in nutritional status during pregnancy has not been empirically examined in Ethiopia. This study aimed to address this gap. Objective: To assess the association of individual and composite women's empowerment dimensions with pregnant women's nutrition outcomes in West Shewa Zone, Ethiopia. Methods: A health facility-based cross-sectional study was performed on 1,453 pregnant women living in West Shewa Zone, Ethiopia, in 2021. Exploratory and confirmatory factor analyses were conducted on half of the samples to identify and validate dimensions of pregnant women's empowerment. The associations between pregnant women's empowerment dimensions and anemia status and mid upper arm circumference levels were examined by logistic regressions. Results: Composite pregnant women's empowerment was positively associated with both anemia status and mid-upper-arm circumference level. The odds of not being anemic were higher among pregnant women empowered in economic [adjusted odds ratio (AOR) = 1.7, 95% confidence interval (CI): 1.26, 2.22] and assertiveness (AOR = 1.9, 95% CI: 1.46, 2.38) dimensions than those not empowered in these dimensions. Empowered pregnant women in household decision-making (AOR = 1.6, 95% CI: 1.19, 2.22) and psychological (AOR = 1.4, 95% CI: 1.04, 1.85) dimensions had higher odds of having normal mid-upper-arm circumference measures than those not empowered in the respective dimensions. Communication and time dimensions were not significantly associated with any of the nutrition outcomes. Conclusions: This study suggests that empowered pregnant women are nutritionally better off than their less empowered counterparts. This is also important in child health outcomes. Policies and programs that aim to improve maternal and child health in the study area need to consider interventions that promote the decision-making power, economic, psychological, and assertiveness dimensions of pregnant women.

Alternative epidemic indicators for COVID-19 in three settings with incomplete death registration systems.

Not all COVID-19 deaths are officially reported, and particularly in low-income and humanitarian settings, the magnitude of reporting gaps remains sparsely characterized. Alternative data sources, including burial site worker reports, satellite imagery of cemeteries, and social media-conducted surveys of infection may offer solutions. By merging these data with independently conducted, representative serological studies within a mathematical modeling framework, we aim to better understand the range of underreporting using examples from three major cities: Addis Ababa (Ethiopia), Aden (Yemen), and Khartoum (Sudan) during 2020. We estimate that 69 to 100%, 0.8 to 8.0%, and 3.0 to 6.0% of COVID-19 deaths were reported in each setting, respectively. In future epidemics, and in settings where vital registration systems are limited, using multiple alternative data sources could provide critically needed, improved estimates of epidemic impact. However, ultimately, these systems are needed to ensure that, in contrast to COVID-19, the impact of future pandemics or other drivers of mortality is reported and understood worldwide.

The role of health education on cervical cancer screening uptake at selected health centers in Addis Ababa.

INTRODUCTION: Cervical cancer is one of the most common causes of morbidity and mortality among women in developing countries including Ethiopia. Unlike other types of cancers, the grave outcomes of cervical cancer could be prevented if detected at its early stage. However, in Ethiopia, awareness about the disease and the availability of screening and treatment services is limited. This study aims to determine the role of health education on cervical cancer screening uptake in selected health facilities in Addis Ababa. METHODS: Two-pronged clustered randomized controlled trial was conducted in 2018 at eight public health centers that provide cervical cancer screening services using visual inspection with acetic acid (VIA) in Addis Ababa, Ethiopia. Each of the eight health centers were randomly assigned to serve as either an intervention or a control center. A two-pronged clustered randomized controlled trial was conducted in eight public health care centers. All the selected facilities provided cervical cancer screening services using visual inspection with acetic acid (VIA). Four health centers were randomly assigned to the intervention and control arms. The study participants were women aged 30-49 years who sought care at maternal and child health clinics but who had never been screened for cervical cancer. In the intervention health centers, all eligible women received one-to-one health education and educational brochures about cervical cancer and cervical cancer screening. In the control health centers, participants received standard care. Baseline data were collected at recruitment and follow-up data were collected two months after the baseline. For the follow-up data collection, participants (both in the intervention and control arms) were interviewed over the phone to check whether they were screened for cervical cancer. RESULT: From the 2,140 women who participated in the study, 215 (10%) screened for cervical cancer, where 152(71%) were from the intervention health centers. Seventy-four percent of these participants reported that they learned about the benefits of screening from the one-to-one health education or the brochure. Women from the intervention health centers had higher odds of getting screened (AOR = 2.43,95%CI;1.58-2.90) than the controls. Women with the educational status of the first degree and those who have a history of sexually transmitted infections (STIs) had higher odds of getting screened (AOR = 2.03,95%CI;(1.15-2.58) and (AOR = 1.55,95%CI;1.01-2.36), respectively. CONCLUSION AND RECOMMENDATION: Providing focused health education supported by printed educational materials increased the uptake of cervical cancer screening services. Integrating one-to-one health education and providing a take-home educational material into the existing maternal and child health services can help increase cervical cancer screening uptake.

Juridification of maternal deaths in Ethiopia: a study of the Maternal and Perinatal Death Surveillance and Response (MPDSR) system.

Juridification of maternal health care is on the rise globally, but little is known about its manifestations in resource constrained settings in sub-Saharan Africa. The Maternal and Perinatal Death Surveillance and Response (MPDSR) system is implemented in Ethiopia to record and review all maternal and perinatal deaths, but underreporting of deaths remains a major implementation challenge. Fear of blame and malpractice litigation among health workers are important factors in underreporting, suggestive of an increased juridification of birth care. By taking MPDSR implementation as an entry point, this article aims to explore the manifestations of juridification of birth care in Ethiopia. Based on multi-sited fieldwork involving interviews, document analysis and observations at different levels of the Ethiopian health system, we explore responses to maternal deaths at various levels of the health system. We found an increasing public notion of maternal deaths being caused by malpractice, and a tendency to perceive the juridical system as the only channel to claim accountability for maternal deaths. Conflicts over legal responsibility for deaths influenced birth care provision. Both health workers and health bureaucrats strived to balance conflicting concerns related to the MPDSR system: reporting all deaths vs revealing failures in service provision. This dilemma encouraged the development of strategies to avoid personalized accountability for deaths. In this context, increased juridification impacted both care and reporting practices. Our study demonstrates the need to create a system that secures legal protection of health professionals reporting maternal deaths as prescribed and provides the public with mechanisms to claim accountability and high-quality birth care services.

Beliefs and intention of heterosexual couples about undertaking Couple's HIV Testing and Counselling (CHTC) services in Ethiopia.

BACKGROUND: Couples HIV Testing & Counselling (CHTC) service is an approach that may enable more people to be reached and tested for HIV. However, little is known about how couples may use this service and what they think about CHTC as an approach to finding out their HIV status. This study aimed to understand how individuals who had ever been in an ongoing heterosexual relationship for 6 months or more intended to use CHTC in Ethiopia and their beliefs about its benefits and potential harms. METHODS: Qualitative in-depth interviews were conducted in Addis Ababa, the capital city of Ethiopia, in 2017. Semi-structured interviews were undertaken with individuals who had ever been in an ongoing heterosexual relationship (n = 21) and key-informants (n = 11) including religious leaders, health care providers, and case managers. The interviews were transcribed verbatim, and an inductive thematic analysis was conducted. The data were coded to look for concepts and patterns across the interviews and relevant themes identified which captured key aspects related to the individual's views on undertaking HIV testing with a sexual partner. RESULTS: Most participants regarded CHTC as an important HIV testing approach for people who are in an ongoing heterosexual relationship and expressed the view that there was "nothing like testing together". However, many of the individual participants revealed they would prefer first to get tested alone to find out their own HIV status. They feared the consequences if they were HIV-positive, including accusations of infidelity, relationship break-up, and being exposed in the community. Many also reported being pressured to undertake CHTC before marriage by a third party, including religious institutions. Key informant interviews also discussed the requirements for CHTC before marriage. CONCLUSION: The findings of this study suggest that people may be concerned about undertaking couples HIV testing without prior individual HIV testing. The intention of many to first test alone has policy and cost implications and underscores the possible harms of the implementation of CHTC in Ethiopia. Future research should examine whether the views identified in this qualitative study are reflected more broadly among couples in the community.

'Maternal deaths should simply be 0': politicization of maternal death reporting and review processes in Ethiopia.

The Maternal Death Surveillance and Response system (MDSR) was implemented in Ethiopia in 2013 to record and review maternal deaths. The overall aim of the system is to identify and address gaps in order to prevent future death but, to date, around 10% of the expected number of deaths are reported. This article examines practices and reasoning involved in maternal death reporting and review practices in Ethiopia, building on the concept of 'practical norms'. The study is based on multi-sited fieldwork at different levels of the Ethiopian health system including interviews, document analysis and observations, and has documented the politicized nature of MDSR implementation. Death reporting and review are challenged by the fact that maternal mortality is a main indicator of health system performance. Health workers and bureaucrats strive to balance conflicting demands when implementing the MDSR system: to report all deaths; to deliver perceived success in maternal mortality reduction by reporting as few deaths as possible; and to avoid personalized accountability for deaths. Fear of personal and political accountability for maternal deaths strongly influences not only reporting practices but also the care given in the study sites. Health workers report maternal deaths in ways that minimize their number and deflect responsibility for adverse outcomes. They attribute deaths to community and infrastructural factors, which are often beyond their control. The practical norms of how health workers report deaths perpetuate a skewed way of seeing problems and solutions in maternal health. On the basis of our findings, we argue that closer attention to the broader political context is needed to understand the implementation of MDSR and other surveillance systems.

Transactional Sex and HIV Risk among Adolescent School Girls in Ethiopia: Mixed Method Study.

BACKGROUND: Young people in Sub-Saharan Africa are affected by HIV pandemic to a greater extent than elsewhere. Transactional sex among adolescent school girls with older men commonly called "sugar daddies" is one of the major factors fueling the spread of the infection due to the extended sexual network. Thus, this study aimed to assess the magnitude and factors associated with transactional sex among adolescent girls and "sugar daddies" in relation to HIV/AIDS. METHODS: Mixed method cross-sectional study was done among 620 female students in Hawassa town, South Ethiopia, from September 2010 to May 2011. A structured questionnaire and in-depth interview check list were used to collect the quantitative and qualitative data, respectively. Survey participants were selected randomly from five preparatory schools whereas ten in-depth interview participants were recruited by a snowball sampling technique from the same schools. Data were entered using Epi-Info and analyzed by SPSS. A descriptive statistics followed by multivariable logistic regression analyses were conducted to identify factors associated with transactional sex with "sugar daddy". Both crude and adjusted odds ratios with 95% confidence interval were reported. We used OpenCode software for coding and categorizing the in-depth interviews and quotes that represent the informants opinion were used to support the quantitative findings. RESULTS: A substantial number of female students, 71(11.5%), reported to have had transactional sex with older men. Most of the respondents who dated "sugar daddies" (93%) had multiple sexual partners concurrently and sequentially, and among them, only 22.7% had consistent condom use. Girls who were in older age group [OR (CI) 6.87 (3.48-13.58)], who had lost both parents [OR (CI) 2.99 (1.14-7.84)], had perceived less economic status [OR: 25.41; 95% CI: 7.80-82.76] and engaged in substance abuse [OR (CO) 5.8 (2.1-15.77)] had higher odds of practicing transactional sex with "sugar daddies". In-depth interviewed participants also revealed that they were involved in transactional sex for monetary while having concurrent and subsequent sexual network with their schoolmates and other young partners. CONCLUSION: Transactional sex among female students was high, and the sexual network they had with the young men put young people in the network at risk of HIV and other sexually transmitted infections. Therefore, HIV prevention programs shall focus on transactional sex among adolescent school girls to halt transmission of HIV among the generation.

Determinants of perinatal mortality among cohorts of pregnant women in three districts of North Showa zone, Oromia Region, Ethiopia: Community based nested case control study.

BACKGROUND: Statistics indicate that Ethiopia has made remarkable progress in reducing child mortality. It is however estimated that there is high rate of perinatal mortality although there is scarcity of data due to a lack of vital registration in the country. This study was conducted with the purpose of assessing the determinants and causes of perinatal mortality among babies born from cohorts of pregnant women in three selected districts of North Showa Zone, Oromia Region, Ethiopia. The study used community based data, which is believed to provide more representative and reliable information and also aimed to narrow the data gap on perinatal mortality. METHODS: A community based nested case control study was conducted among 4438 (cohorts of) pregnant women. The cohort was followed up between March 2011 to December 2012 in three districts of Oromia region, Ethiopia, until delivery. The World Health Organization verbal autopsy questionnaire for neonatal death was used to collect data. A binary logistic regression model was used to identify determinants of perinatal mortality. Causes of deaths were assigned by a pediatrician and neonatologist. Cases are stillbirths and early neonatal death. Control are live births surviving of the perinatal period' RESULT: A total of 219 newborns (73 cases and 146 controls) were included in the analysis. Perinatal mortality rate was 16.5 per 1000 births. Mothers aged 35 years and above had a higher risk of losing their newborn babies to perinatal deaths than younger mothers [AOR 7.59, (95% CI, 1.91-30.10)]. Babies born to mothers who had a history of neonatal deaths were also more likely to die during the perinatal period than their counterparts [AOR 5.42, (95% CI, 2.27-12.96)]. Preterm births had a higher risk of perinatal death than term babies [AOR 8.58, (95% CI, 2.27-32.38)]. Similarly, male babies were at higher risk than female babies [AOR 5.47, (95% CI, 2.50-11.99)]. Multiple birth babies had a higher chance of dying within the perinatal period than single births [AOR 3.59, (95% CI, 1.20-10.79)]. Home delivery [AOR 0.23, (95% CI, 0.08-0.67)] was found to reduce perinatal deaths. Asphyxia, sepsis and chorioamnionitis were among the leading causes of perinatal deaths. CONCLUSION: This study reported a lower perinatal mortality rate. The main causes of perinatal death identified were often related to maternal factors. There is still a need for greater focus on these interrelated issues for further intervention.

Selling my sheep to pay for medicines - household priorities and coping strategies in a setting without universal health coverage.

BACKGROUND: The first month of life is the period with the highest risk of dying. Despite knowledge of effective interventions, newborn mortality is high and utilization of health care services remains low in Ethiopia. In settings without universal health coverage, the economy of a household is vulnerable to illness, and out-of-pocket payments may limit families' opportunities to seek health care for newborns. In this paper we explore intra-household resource allocation, focusing on how families prioritize newborn health versus other household needs and their coping strategies for managing these priorities. METHODS: A qualitative study was conducted in 2015 in Butajira, Ethiopia, comprising observation, semi-structured interviews, and focus group discussions with household members, health workers, and community members. Household members with hospitalized newborns or who had experienced neonatal death were primary informants. RESULTS: In this predominantly rural and poor district, households struggled to pay out-of-pocket for services such as admission, diagnostics, drugs, and transportation. When newborns fell ill, families made hard choices balancing concerns for newborn health and other household needs. The ability to seek care, obtain services, and follow medical advice depended on the social and economic assets of the household. It was common to borrow money from friends and family, or even to sell a sheep or the harvest, if necessary. In managing household priorities and high costs, families waited before seeking health care, or used cheaper traditional medicines. For poor families with no money or opportunity to borrow, it became impossible to follow medical advice or even seek care in the first place. This had fatal health consequences for the sick newborns. CONCLUSIONS: While improving neonatal health is prioritized at policy level in Ethiopia, poor households with sick neonates may prioritize differently. With limited money at hand and high direct health care costs, families balanced conflicting concerns to newborn health and family welfare. We argue that families should not be left in situations where they have to choose between survival of the newborn and economic ruin. Protection against out-of-pocket spending is key as Ethiopia moves towards universal health coverage. A necessary step is to provide prioritized newborn health care services free of charge.

Injury-related gaining momentum as external causes of deaths in Ethiopian health and demographic surveillance sites: evidence from verbal autopsy study.

BACKGROUND: In Ethiopia, though all kinds of mortality due to external causes are an important component of overall mortality often not counted or documented on an individual basis. OBJECTIVE: The aim of this study was to describe the patterns of mortality from external causes using verbal autopsy (VA) method at the Ethiopian HDSS Network sites. METHODS: All deaths at Ethiopian HDSS sites were routinely registered and followed up with VA interviews. The VA forms comprised deaths up to 28 days, between four weeks and 14 years and 15 years and above. The cause of a death was ascertained based on an interview with next of families or other caregivers using a standardized questionnaire that draws information on signs, symptoms, medical history and circumstances preceding death after 45 days mourning period. Two physician assigned probable causes of death as underlying, immediate and contributing factors independently using information in VA forms based on the WHO ICD-10 and VA code system. Disagreed cases sent to third physician for independent review and diagnosis. The final cause of death considered when two of the three physicians assigned underlying cause of death; otherwise, labeled as undetermined. RESULTS: In the period from 2009 to 2013, a total of 9719 deaths were registered. Of the total deaths, 623 (6.4%) were from external causes. Of these, accidental drowning and submersion, 136 (21.8%), accidental fall, 113 (18.1%) and transport-related accidents, 112 (18.0%) were the topmost three leading external causes of deaths. About 436 (70.0%) of deaths were from the age group above 15 years old. Drowning and submersion and transport-related accidents were high in age group between 5 and 14 years old. CONCLUSION: In this study, external causes of death are significant public health problems and require attention as one of prior health agenda.

What if the baby doesn't survive? Health-care decision making for ill newborns in Ethiopia.

Despite efforts to improve access to and quality of care for newborns, the first month after birth remains the most dangerous period of life. Given high neonatal mortality in low-income countries, saving newborn lives is a key priority for global and national health policy agendas. However, little is known about how these policies resonate with local understandings, experiences and household priorities. In this qualitative study we examined families' decision making and health-care-seeking in Butajira, Ethiopia. Data were collected through observation in hospital, in-depth interviews (41), and focus group discussions (7) with family members, health-care workers, and community members (October-November 2015). Transcripts and field notes were analyzed inductively using qualitative content analysis. Findings indicate that newborn health was not always the family's priority. Local perceptions of newborns as not yet useful members of the household alongside costly health-care services delayed decision making and care-seeking. While sickness was recognized as dangerous for the ill newborn, seeking health-care could be harmful for the economic survival of the family. In a resource-constrained setting, families' focused on productive assets in order to minimize long-term risks, and waited before seeking newborn health-care services. Until the baby had survived the first vulnerable weeks and months of life, the unknown newborn was not yet seen as a social person by the community. Personhood evolved progressively as the baby became a part of the family. A newborn death was surrounded by silence, and families received minimal support from traditional financial associations, iddirs. Decisions regarding health-care were contingent upon families' understandings of newborns and their resource-constrained circumstances. Improving newborn health involves recognizing why families choose to (not) seek health-care, and their actual opportunities and constraints in making such decisions. The everyday realities of vulnerable newborns must be at the center of global and national policy discussions and local implementation.

High proportions of obstetric referrals in Addis Ababa: the case of term premature rupture of membranes.

BACKGROUND: The Public Health Centers (HCs) provide basic obstetric and neonatal care to about 80% of the eligible population in Addis Ababa. Hospitals provide comprehensive services and are referral centers for complications that cannot be managed at the HCs. This study assessed the proportion of obstetric referrals in general and referrals due to premature rupture of membranes (PROM) at term in particular, from the HCs in Addis Ababa and explored its appropriateness and management in hospitals. METHODS: The study used a sequential explanatory mixed methods design. Routine retrospective data were collected from ten randomly selected HCs in 2012. Key informant interviews were conducted using a guide developed following a preliminary analysis of the quantitative data. Ten head midwives, one from each health center participated in the interviews. RESULTS: Of the 9340 mothers who sought skilled birth care in the ten HCs in 2012, 2820 (30.3%) were diagnosed with obstetric complications and referred to hospital. Term PROM accounted for 557 (19.7%) of the referrals and it was widely varied across the HCs. Fifteen (7.8%) mothers who were referred for PROM, had intact membranes upon hospital examinations. Forty-two (77.8%) of the referred mothers who had spontaneous labour and delivery could have been misclassified as not having labour upon referral. In the interviews, variations in diagnosing and managing term PROM were identified as themes. Three HCs relayed solely on mothers' self reports of amniotic fluid leakage to diagnose, two HCs did complementary speculum/vaginal examination, three HCs monitored sign of labour on top of confirming the leakage. Regarding management, two HCs practiced expectant management, three referred mothers after 30 min of observation while others issued referral right away. All providers reported the lack of clinical guidelines for most common obstetric problems in their HC. CONCLUSIONS: The study reported large proportion of obstetric referrals in general and PROM referrals in particular as well as variations in diagnosing and managing term PROM. These could largely be attributed to lack of clinical guidelines for most common obstetric complications at the HCs and competency gap among providers. Addressing the identified gaps and strengthening the primary care settings could contribute to improved quality of obstetric care and outcomes.

Menstrual hygiene management and school absenteeism among female adolescent students in Northeast Ethiopia.

BACKGROUND: Adolescence in girls has been recognized as a special period marked with the onset of menarche. Even though menstruation is a natural process, it is associated with misconceptions, malpractices and challenges among girls in developing countries. However, much is not documented; school-absenteeism and dropout are a common problem among girls in rural Ethiopia. Focusing among school girls, this study has examined knowledge about menstruation, determinants of menstrual management and its influence on school-attendance in Northeast Ethiopia. METHODS: We conducted a mixed-method research combining quantitative and qualitative methods in Northeast Ethiopia. The quantitative study was conducted among 595 randomly selected adolescent school girls. Nine in-depth interviews; five school-dropout girls and four female teachers, and four focus group discussions among school girls were conducted in 2013. RESULTS: The mean age at menarche was 13.98 (±1.17) years. About 51% of girls had knowledge about menstruation and its management. Only a third of the girls used sanitary napkins as menstrual absorbent during their last menstruation. Girls from urban areas, had mothers of secondary and above education and, families of higher monthly expenditure had more chance of using sanitary napkins than their counterparts. More than half of the girls reported to have been absent from school during their menstruation period. Those who did not use sanitary napkins were more likely to be absent from school [AOR-95% C.I: 5.37 (3.02 - 9.55)]. Fifty eight percent of girls reported that their school-performance had declined after they had menarche. In addition, the qualitative study indicated that school-dropout was common among girls who experienced teasing and humiliation by classmates when their clothes were stained with blood as they do not use sanitary napkins. CONCLUSION: Though there is an effort to increase girls' school enrollment, lack of basic needs, like sanitary napkins that facilitate routine activates of girls at early adolescence are observed to deter girls' school-attendance in rural Ethiopia. Special support for girl students, especially when they have their first menstruation and separate functioning sanitary facilities are necessities that should be in school at all times if gender equality and girls empowerment is to be achieved.

Current evidence on basic emergency obstetric and newborn care services in Addis Ababa, Ethiopia; a cross sectional study.

BACKGROUND: Emergency obstetric and neonatal care (EmONC) is a high impact priority intervention highly recommended for improving maternal and neonatal health outcomes. In 2008, Ethiopia conducted a national EmONC survey that revealed implementation gaps, mainly due to resource constraints and poor competence among providers. As part of an ongoing project, this paper examined progress in the implementation of the basic EmONC (BEmONC) in Addis Ababa and compared with the 2008 survey. METHODS: A facility based intervention project was conducted in 10 randomly selected public health centers (HCs) in Addis Ababa and baseline data collected on BEmONC status from January to March 2013. Retrospective routine record reviews and facility observations were done in 29 HCs in 2008 and in10 HCs in 2013. Twenty-five providers in 2008 and 24 in 2013 participated in BEmONC knowledge and skills assessment. All the data were collected using standard tools. Descriptive statistics and t-tests were used. RESULTS: In 2013, all the surveyed HCs had continuous water supply, reliable access to telephone, logbooks & phartograph. Fifty precent of the HCs in 2013 and 34% in 2008 had access to 24 hours ambulance services. The ratio of midwives to 100 expected births were 0.26 in 2008 and 10.3 in 2013. In 2008, 67% of the HCs had a formal fee waiver system while all the surveyed HCs had it in 2013. HCs reporting a consistent supply of uterotonic drugs were 85% in 2008 and 100% in 2013. The majority of the providers who participated in both surveys reported to have insufficient knowledge in diagnosing postpartum haemorrhage (PPH) and birth asphyxia as well as poor skills in neonatal resuscitation. Comparing with the 2008 survey, no significant improvements were observed in providers' knowledge and competence in 2013 on PPH management and essential newborn care (p > 0.05). CONCLUSION: There are advances in infrastructure, medical supplies and personnel for EmONC provision, yet poor providers' competences have persisted contributing to the quality gaps on BEmONC in Addis Ababa. Considering short-term in-service trainings using novel approaches for ensuring desired competences for large number of providers in short time period is imperative.

Standard basic emergency obstetric and neonatal care training in Addis Ababa; trainees reaction and knowledge acquisition.

BACKGROUND: In 2010, the Federal Ministry of Health of Ethiopia (FMOH) has developed standard Basic Emergency Obstetric and Neonatal Care (BEmONC) in-service training curricula to respond to the high demand for competency in EmONC. However, the effectiveness of the training curricula has not been well documented. A collaborative intervention project in Addis Ababa has trained providers using the standard BEmONC curricula where this paper presents Krikpartick level 1 and level 2 evaluation of the training. METHODS: The project has been conducted in 10 randomly selected public health centers (HC) in Addis Ababa. Providers working in the labour wards of the selected HCs have received the standard BEmONC training between May and July 2013. Using standard tools, trainees' reaction to the course and factual knowledge during the immediate post-course and six months after the training were assessed. Descriptive statistics and t-tests were done. RESULTS: Of the total 82 providers who received the training, 30 (36.6%) were male, 61 (74.4%) were midwives. Providers' work experiences ranged from 1 month to 37 years. Seventy-four (89%) providers reported that the training was appropriate for their work, 95% reported that the training have updated their knowledge & skills, while 27 (32.9%) reported that the training facilities & arrangements were unsatisfactory. The mean immediate post-course knowledge score was 83.5% and 33 (40%) providers did not achieve knowledge-based mastery in their first attempt. The midwives were more likely to achieve knowledge-based mastery than the nurses (p < 0.05). The mean knowledge score six-months post-training was 80.2% and 40% have scored knowledge based mastery. CONCLUSIONS: Being one of the first papers reporting the implementation of the standard in-service BEmONC training curriculum, we have identified an important limitation on the course evaluations of the curriculum, which need urgent consideration. The majority of the trainees has reported favourable reaction to the training, but many of them did not achieve knowledge-based mastery in the immediate post training although the knowledge retention six months post training was encouraging.

A qualitative study of attitudes and values surrounding stillbirth and neonatal mortality among grandmothers, mothers, and unmarried girls in rural Amhara and Oromiya regions, Ethiopia: unheard souls in the backyard.

INTRODUCTION: In Ethiopia, neonatal mortality and stillbirth are high and underreported. This study explored values related to neonatal mortality and stillbirth and the visibility of these deaths in rural Ethiopia among 3 generations of women. METHODS: We conducted a qualitative study in 6 rural districts of the Oromiya and Amhara regional states during May 2012. We included 30 focus groups representing grandmothers, married women (mothers), and unmarried girls in randomly selected kebeles (villages). RESULTS: Until the 40th day of life, neonates are considered to be strangers to the community (not human). Their deaths are not talked about; they are buried in the house or in the backyard. Mothers are forbidden to mourn their loss lest they offend God and bring on future neonatal losses. Women who repeatedly lose their neonates may be blamed, mistreated, and dishonored through divorce. Neonatal death and stillbirth are attributed to supernatural powers, although some women and girls associate these deaths with poverty and lack of education. The desire for increased visibility of neonatal death is mixed. Unlike the grandmothers and unmarried girls, most of the married women want death to be visible to draw the attention of policy makers. Women prefer home birth and consider themselves lucky to be able to give birth at home. At present, there is no national vital registration system. DISCUSSION: Neonatal death and stillbirth are hidden and the magnitude is likely underrepresented. The delayed recognition of personhood, attribution of death to supernatural causes, social repercussions for women who experience a pregnancy loss, preference for home birth, and lack of a vital registration system all contribute to the invisibility of perinatal deaths. Increasing the visibility of (and counting) these deaths may require multifaceted behavior-change interventions.

Comparing HIV prevalence estimates from prevention of mother-to-child HIV transmission programme and the antenatal HIV surveillance in Addis Ababa.

BACKGROUND: In the absence of reliable data, antenatal HIV surveillance has been used to monitor the HIV epidemic since the late 1980s. Currently, routine data from Prevention of Mother-to-child HIV transmission (PMTCT) programmes are increasingly available. Evaluating whether the PMTCT programme reports provide comparable HIV prevalence estimates with the antenatal surveillance reports is important. In this study, we compared HIV prevalence estimates from routine PMTCT programme and antenatal surveillance in Addis Ababa with the aim to come up with evidence based recommendation. METHODS: Summary data were collected from PMTCT programmes and antenatal surveillance reports within the catchment of Addis Ababa. The PMTCT programme data were obtained from routine monthly reports from 2004 to 2009 and from published antenatal HIV surveillance reports from 2003 to 2009. Data were analysed using descriptive statistics. RESULTS: In Addis Ababa, PMTCT sites had increased from six in 2004 to 54 in 2009. The site expansion was accompanied by an increased number of women testing. There were marked increases in the rate of HIV testing following the introduction of routine opt-out HIV testing approach. Paralleling these increases, the HIV prevalence showed a steady decline from 10.0% in 2004 to 4.5% in 2009. There were five antenatal surveillance sites from 2003 to 2007 in Addis Ababa and they increased to seven by 2009. Four rounds of surveillance data from five sites showed a declining trend in HIV prevalence over the years. The overall antenatal surveillance data also showed that the HIV prevalence among antenatal attendees had declined from 12.4% in 2003 to 5.5% in 2009. The HIV prevalence estimates from PMTCT programme were 6.2% and 4.5% and from antenatal surveillance 6.1 and 5.5% in 2008 and 2009 respectively. CONCLUSIONS: There were consistent HIV prevalence estimates from PMTCT programme and from antenatal surveillance reports. Both data sources showed a marked decline in HIV prevalence among antenatal care attendees in Addis Ababa. This study concludes that the routine data from the PMTCT programmes in Addis Ababa provides comparable HIV prevalence estimates with antenatal HIV surveillance data and could be used for monitoring trends.

Current status of medication adherence and infant follow up in the prevention of mother to child HIV transmission programme in Addis Ababa: a cohort study.

BACKGROUND: Prevention of mother to child HIV transmission (PMTCT) programmes have great potential to achieve virtual elimination of perinatal HIV transmission provided that PMTCT recommendations are properly followed. This study assessed mothers and infants adherence to medication regimen for PMTCT and the proportions of exposed infants who were followed up in the PMTCT programme. METHODS: A prospective cohort study was conducted among 282 HIV-positive mothers attending 15 health facilities in Addis Ababa, Ethiopia. Descriptive statistics, bivariate and mulitivariate logistic regression analyses were done. RESULTS: Of 282 mothers enrolled in the cohort, 232 (82%, 95% CI 77-86%) initiated medication during pregnancy, 154 (64%) initiated combined zidovudine (ZDV) prophylaxis regimen while 78 (33%) were initiated lifelong antiretroviral treatment (ART). In total, 171 (60%, 95% CI 55-66%) mothers ingested medication during labour. Of the 221 live born infants (including two sets of twins), 191 (87%, 95% CI 81-90%) ingested ZDV and single-dose nevirapine (sdNVP) at birth. Of the 219 live births (twin births were counted once), 148 (68%, 95% CI 61-73%) mother-infant pairs ingested their medication at birth. Medication ingested by mother-infant pairs at birth was significantly and independently associated with place of delivery. Mother-infant pairs attended in health facilities at birth were more likely (OR 6.7 95% CI 2.90-21.65) to ingest their medication than those who were attended at home. Overall, 189 (86%, 95% CI 80-90%) infants were brought for first pentavalent vaccine and 115 (52%, 95% CI 45-58%) for early infant diagnosis at six-weeks postpartum. Among the infants brought for early diagnosis, 71 (32%, 95% CI 26-39%) had documented HIV test results and six (8.4%) were HIV positive. CONCLUSIONS: We found a progressive decline in medication adherence across the perinatal period. There is a big gap between mediation initiated during pregnancy and actually ingested by the mother-infant pairs at birth. Follow up for HIV-exposed infants seem not to be organized and is inconsistent. In order to maximize effectiveness of the PMTCT programme, the rate of institutional delivery should be increased, the quality of obstetric services should be improved and missed opportunities to exposed infant follow up should be minimized.