Analysis of maternal and newborn training curricula and approaches to inform future trainings for routine care, basic and comprehensive emergency obstetric and newborn care in the low- and middle-income countries: Lessons from Ethiopia and Nepal.

Program managers routinely design and implement specialised maternal and newborn health trainings for health workers in low- and middle-income countries to provide better-coordinated care across the continuum of care. However, in these countries details on the availability of different training packages, skills covered in those training packages and the gaps in their implementation are patchy. This paper presents an assessment of maternal and newborn health training packages to describe differences in training contents and implementation approaches used for a range of training packages in Ethiopia and Nepal. We conducted a mixed-methods study. The quantitative assessment was conducted using a comprehensive assessment questionnaire based on validated WHO guidelines and developed jointly with global maternal and newborn health experts. The qualitative assessment was conducted through key informant interviews with national stakeholders involved in implementing these training packages and working with the Ministries of Health in both countries. Our quantitative analysis revealed several key gaps in the technical content of maternal and newborn health training packages in both countries. Our qualitative results from key informant interviews provided additional insights by highlighting several issues with trainings related to quality, skill retention, logistics, and management. Taken together, our findings suggest four key areas of improvement: first, training materials should be updated based on the content gaps identified and should be aligned with each other. Second, trainings should address actual health worker performance gaps using a variety of innovative approaches such as blended and self-directed learning. Third, post-training supervision and ongoing mentoring need to be strengthened. Lastly, functional training information systems are required to support planning efforts in both countries.

Changes in attitudes and behaviors supportive of maternal and newborn health in Ethiopia: an evaluative case study.

BACKGROUND: Ethiopia's high neonatal mortality rate led to the government's 2013 introduction of Community-Based Newborn Care (CBNC) to bring critical prevention and treatment interventions closer to communities in need. However, complex behaviors that are deeply embedded in social and cultural norms continue to prevent women and newborns from getting the care they need. A demand creation strategy was designed to create an enabling environment to support appropriate maternal, newborn, and child health (MNCH) behaviors and CBNC. We explored the extent to which attitudes and behaviors during the prenatal and perinatal periods varied by the implementation strength of the Demand Creation Strategy for MNCH-CBNC. METHODS: Using an embedded, multiple case study design, we purposively selected four kebeles (villages) from two districts with different levels of implementation strength of demand creation activities. We collected information from a total of 150 key stakeholders across kebeles using multiple qualitative methods including in-depth interviews, focus group discussions, and illness narratives; sessions were transcribed into English and coded using NVivo 10.0. We developed case reports for each kebele and a final cross-case report to compare results from high and low implementation strength kebeles. RESULTS: We found that five MNCH attitudes and behaviors varied by implementation strength. In high implementation strength kebeles women felt more comfortable disclosing their pregnancy early, women sought antenatal care (ANC) in the first trimester, families did not have fatalistic ideas about newborn survival, mothers sought care for sick newborns in a timely manner, and newborns received care at the health facility in less than an hour. We also found changes across all kebeles that did not vary by implementation strength, including male engagement during pregnancy and a preference for giving birth at a health facility. CONCLUSIONS: Findings suggest that a demand creation approach-combining participatory approaches with community empowering strategies-can promote shifts in behaviors and attitudes to support the health of mothers and newborns, including use of MNCH services. Future studies need to consider the most efficient level of intervention intensity to make the greatest impact on MNCH attitudes and behaviors.

Community-Based Interventions for Newborns in Ethiopia (COMBINE): Cost-effectiveness analysis.

About 87 000 neonates die annually in Ethiopia, with slower progress than for child deaths and 85% of births are at home. As part of a multi-country, standardized economic evaluation, we examine the incremental benefit and costs of providing management of possible serious bacterial infection (PSBI) for newborns at health posts in Ethiopia by Health Extension Workers (HEWs), linked to improved implementation of existing policy for community-based newborn care (Health Extension Programme). The government, with Save the Children/Saving Newborn Lives and John Snow, Inc., undertook a cluster randomized trial. Both trial arms involved improved implementation of the Health Extension Programme. The intervention arm received additional equipment, support and supervision for HEWs to identify and treat PSBI. In 2012, ∼95% of mothers in the study area received at least one pregnancy or postnatal visit in each arm, an average of 5.2 contacts per mother in the intervention arm (4.9 in control). Of all visits, 79% were conducted by volunteer community health workers. HEWs spent around 9% of their time on the programme. The financial cost per mother and newborn was $34 (in 2015 USD) in the intervention arm ($27 in control), economic costs of $37 and $30, respectively. Adding PSBI management at community level was estimated to reduce neonatal mortality after day 1 by 17%, translating to a cost per DALY averted of $223 or 47% of the GDP per capita, a highly cost-effective intervention by WHO thresholds. In a routine situation, the intervention programme cost would represent 0.3% of public health expenditure per capita and 0.5% with additional monthly supervision meetings. A platform wide approach to improved supervision including a dedicated transport budget may be more sustainable than a programme-specific approach. In this context, strengthening the existing HEW package is cost-effective and also avoids costly transfers to health centres/hospitals.

Effect on Neonatal Mortality of Newborn Infection Management at Health Posts When Referral Is Not Possible: A Cluster-Randomized Trial in Rural Ethiopia.

BACKGROUND: The World Health Organization recently provided guidelines for outpatient treatment of possible severe bacterial infections (PSBI) in young infants, when referral to hospital is not feasible. This study evaluated newborn infection treatment at the most peripheral level of the health system in rural Ethiopia. METHODS: We performed a cluster-randomized trial in 22 geographical clusters (11 allocated to intervention, 11 to control). In both arms, volunteers and government-employed Health Extension Workers (HEWs) conducted home visits to pregnant and newly delivered mothers; assessed newborns; and counseled caregivers on prevention of newborn illness, danger signs, and care seeking. Volunteers referred sick newborns to health posts for further assessment; HEWs referred newborns with PSBI signs to health centers. In the intervention arm only, between July 2011 and June 2013, HEWs treated newborns with PSBI with intramuscular gentamicin and oral amoxicillin for 7 days at health posts when referral to health centers was not possible or acceptable to caregivers. Intervention communities were informed of treatment availability at health posts to encourage care seeking. Masking was not feasible. The primary outcome was all-cause mortality of newborns 2-27 days after birth, measured by household survey data. Baseline data were collected between June 2008 and May 2009; endline data, between February 2013 and June 2013. We sought to detect a 33% mortality reduction. Analysis was by intention to treat. (ClinicalTrials.gov registry: NCT00743691). RESULTS: Of 1,011 sick newborns presenting at intervention health posts, 576 (57%) were identified by HEWs as having at least 1 PSBI sign; 90% refused referral and were treated at the health post, with at least 79% completing the antibiotic regimen. Estimated treatment coverage at health posts was in the region of 50%. Post-day 1 neonatal mortality declined more in the intervention arm (17.9 deaths per 1,000 live births at baseline vs. 9.4 per 1,000 at endline) than the comparison arm (14.4 per 1,000 vs. 11.2 per 1,000, respectively). After adjusting for baseline mortality and region, the estimated post-day 1 mortality risk ratio was 0.83, but the result was not statistically significant (95% confidence interval, 0.55 to 1.24; P=.33). INTERPRETATION: When referral to higher levels of care is not possible, HEWs can deliver outpatient antibiotic treatment of newborns with PSBI, but estimated treatment coverage in a rural Ethiopian setting was only around 50%. While our data suggest a mortality reduction consistent with that which might be expected at this level of coverage, they do not provide conclusive results.

How do health extension workers in Ethiopia allocate their time?

BACKGROUND: Governments are increasingly reliant on community health workers to undertake health promotion and provide essential curative care. In 2003, the Government of Ethiopia launched the Health Extension Programme and introduced a new cadre, health extension workers (HEWs), to improve access to care in rural communities. In 2013, to inform the government's plans for HEWs to take on an enhanced role in community-based newborn care, a time and motion study was conducted to understand the range of HEW responsibilities and how they allocate their time across health and non-health activities. METHODS: The study was administered in 69 rural kebeles in the Southern Nations Nationalities and People's Region and Oromia Region that were intervention areas of a trial to evaluate a package of community-based interventions for newborns. Over 4 consecutive weeks, HEWs completed a diary and recorded all activities undertaken during each working day. HEWs were also surveyed to collect data on seasonal activities and details of the health post and kebele in which they work. The average proportion of productive time (excluding breaks) that HEWs spent on an activity, at a location, or with a recipient each week, was calculated. RESULTS: The self-reported diary was completed by 131 HEWs. Over the course of a week, HEWs divided their time between the health post (51%) and the community (37%), with the remaining 11% of their time spent elsewhere. Curative health activities represented 16% of HEWs' time each week and 43% of their time was spent on health promotion and prevention. The remaining time included travel, training and supervision, administration, and community meetings. HEWs spent the majority (70%) of their time with individuals, families, and community members. CONCLUSIONS: HEWs have wide-ranging responsibilities for community-based health promotion and curative care. Their workload is diverse and they spend time on activities relating to family health, disease prevention and control, hygiene and sanitation, as well as other community-based activities. Reproductive, maternal, newborn, and child health activities represent a major component of the HEW's work and, as such, they can have a critically important role in improving the health outcomes of mothers and children in Ethiopia.

Factors influencing the low utilization of curative child health services in Shebedino District, Sidama Zone, Ethiopia.

BACKGROUND: Use and coverage of curative interventions for childhood pneumonia, diarrhea, and malaria were low in Ethiopia before integrated community-based case management (iCCM). OBJECTIVES: To examine factors accounting for low use of iCCMin Shebedino District applying a "Pathway to Sur- vival" approach to assess illness recognition; home care; labeling and decision-making; patterns of care-seeking; access, availability and quality of care; and referral. METHODS: Shortly after introduction of iCCM, we conducted five studies in Shebedino District in May 2011: a population-based household survey; focus group discussions of mothers of recently ill children; key informant in- terviews, including knowledge assessment, with Health Extension Workers at health posts and with health workers at health centers; and an inventory of drugs, supplies, and job aids at health posts and health centers. RESULTS: The many barriers to use of evidence-based treatment included: (1) home remedies of uncertain effect and safety that delay care-seeking; (2) absent decision-maker; (3) fear of stigma; (4) expectation of non-availability of service or medicine; (5) geographic and financial barriers; (6) perception of (or actual) poor quality of care; and (7) accessible, available, affordable, reliable, non-standard, alternative sources of care. CONCLUSION: Only a system-strengthening approach can overcome such manifold barriers to use of curative care that has not increased much after ICCM introduction.

Assessment of the monitoring and evaluation system for integrated community case management (ICCM) in Ethiopia: a comparison against global benchmark indicators.

BACKGROUND: Program managers require feasible, timely, reliable, and valid measures of iCCM implementation to identify problems and assess progress. The global iCCM Task Force developed benchmark indicators to guide implementers to develop or improve monitoring and evaluation (M&E) systems. OBJECTIVE: To assesses Ethiopia's iCCM M&E system by determining the availability and feasibility of the iCCM benchmark indicators. METHODS: We conducted a desk review of iCCM policy documents, monitoring tools, survey reports, and other rele- vant documents; and key informant interviews with government and implementing partners involved in iCCM scale-up and M&E. RESULTS: Currently, Ethiopia collects data to inform most (70% [33/47]) iCCM benchmark indicators, and modest extra effort could boost this to 83% (39/47). Eight (17%) are not available given the current system. Most benchmark indicators that track coordination and policy, human resources, service delivery and referral, supervision, and quality assurance are available through the routine monitoring systems or periodic surveys. Indicators for supply chain management are less available due to limited consumption data and a weak link with treatment data. Little information is available on iCCM costs. CONCLUSION: Benchmark indicators can detail the status of iCCM implementation; however, some indicators may not fit country priorities, and others may be difficult to collect. The government of Ethiopia and partners should review and prioritize the benchmark indicators to determine which should be included in the routine M&E system, especially since iCCMdata are being reviewed for addition to the HMIS. Moreover, the Health Extension Worker's reporting burden can be minimized by an integrated reporting approach.

Neonatal mortality in Ethiopia: trends and determinants.

BACKGROUND: The Ethiopian neonatal mortality rate constitutes 42% of under-5 deaths. We aimed to examine the trends and determinants of Ethiopian neonatal mortality. METHODS: We analyzed the birth history information of live births from the 2000, 2005 and 2011 Ethiopia Demographic and Health Surveys (DHS). We used simple linear regression analyses to examine trends in neonatal mortality rates and a multivariate Cox proportional hazards regression model using a hierarchical approach to examine the associated factors. RESULTS: The neonatal mortality rate declined by 1.9% per annum from 1995 to 2010, logarithmically. The early neonatal mortality rate declined by 0.9% per annum and was where 74% of the neonatal deaths occurred. Using multivariate analyses, increased neonatal mortality risk was associated with male sex (hazard ratio (HR) = 1.38; 95% confidence interval (CI), 1.23 - 1.55); neonates born to mothers aged < 18 years (HR = 1.41; 95% CI, 1.15 - 1.72); and those born within 2 years of the preceding birth (HR = 2.19; 95% CI, 1.89 - 2.51). Winter birth increased the risk of dying compared with spring births (HR = 1.28; 95% CI, 1.08 - 1.51). Giving two Tetanus Toxoid Injections (TTI) to the mothers before childbirth decreased neonatal mortality risk (HR = 0.44; 95% CI, 0.36 - 0.54). Neonates born to women with secondary or higher schooling vs. no education had a lower risk of dying (HR = 0.68; 95% CI, 0.49 - 0.95). Compared with neonates in Addis Ababa, neonates in Amhara (HR: 1.88; 95% CI: 1.26 - 2.83), Benishangul Gumuz (HR: 1.75; 95% CI: 1.15 - 2.67) and Tigray (HR: 1.54; 95% CI: 1.01 - 2.34) regions carried a significantly higher risk of death. CONCLUSIONS: Neonatal mortality must decline more rapidly to achieve the Millennium Development Goal (MDG) 4 target for under-5 mortality in Ethiopia. Strategies to address neonatal survival require a multifaceted approach that encompasses health-related and other measures. Addressing short birth interval and preventing early pregnancy must be considered as interventions. Programs must improve the coverage of TTI and prevention of hypothermia for winter births should be given greater emphasis. Strategies to improve neonatal survival must address inequalities in neonatal mortality by women's education and region.

Barriers to and facilitators for female participation in an HIV prevention project in rural Ethiopia: findings from a qualitative evaluation.

Ethiopian women face complex social and cultural factors that influence their probability of HIV infection. HIV prevention efforts among this population are particularly important; however, female participation in a rural, HIV prevention project has been minimal. This programme evaluation investigated barriers and facilitators influencing women's ability to participate in project activities. Evaluation data were collected through nine focus groups and 20 semi-structured interviews, which were conducted between October and November 2003. The main themes found to negatively influence women's decisions to participate in this HIV prevention activity included: domestic workloads, lack of education and awareness, and cultural norms that have discouraged discussions about HIV and sexuality. Domestic chores, which are labour intensive and limit time and energy, were found to be the primary barrier to participation among women. Respondents also indicated that female illiteracy and limited educational attainment occur within a social context that traditionally supports education for men but discourages formal knowledge among women, including HIV prevention. Lack of education and inability to freely discuss sexuality denies women access to health information, potentially exposing women to adverse consequences such as HIV infection. Identified facilitators of participation included a radio serial drama and the one female peer educator associated with the project.