Institutionalization of limited obstetric ultrasound leading to increased antenatal, skilled delivery, and postnatal service utilization in three regions of Ethiopia: A pre-post study.

BACKGROUND: A minimum of one ultrasound scan is recommended for all pregnant women before the 24th week of gestation. In Ethiopia, there is a shortage of skilled manpower to provide these services. Currently, trained mid-level providers are providing the services at the primary healthcare level. The aims of this study were to compare antenatal care 1 (ANC1), antenatal care 4 (ANC4), skilled birth attendance (SBA), and postnatal care (PNC) service utilization before and after institutionalizing Vscan limited obstetric ultrasounds at semi-urban health centers in Ethiopia. METHODS: A pre and post intervention observational study was conducted to investigate maternal and neonatal health service utilization rates before and after institutionalizing Vscan limited obstetric ultrasound services, between July 2016 and June 2020. The data were extracted from 1st August- 31st December 2020. RESULTS: The observed monthly increase on the mean rank of first ANC visits after the introduction of Vscan limited obstetric ultrasound services showed a statistically significant difference at KW-ANOVA H (3) = 17.09, P = 0.001. The mean rank of fourth ANC utilization showed a statistically significant difference at KW- ANOVA H (3) = 16.24, P = 0.001. The observed mean rank in skilled birth attendance (SBA) showed a statistically significant positive difference using KW-ANOVA H (3) = 23.6, P<0.001. The mean rank of increased utilization in postnatal care showed a statistically significant difference using KW-ANOVA H (3) = 17.79, P<0.001. CONCLUSION: The introduction of limited obstetric ultrasound services by trained mid-level providers at the primary healthcare level was found to have improved the utilization of ANC, SBA, and postnatal care (PNC) services. It is recommended that the institutionalization of limited obstetric ultrasound services be scaled up and a further comparative study between facilities with and without ultrasound services be conducted to confirm causality and assess effects on maternal and perinatal outcomes.

Two decades of family planning in Ethiopia and the way forward to sustain hard-fought gains!

Family planning (FP) is a human right, and ensuring women's access to FP is central to protecting the health and wellbeing of mothers and children. Over the past two decades, Ethiopia has made FP service more widely available, increasing the contraceptive prevalence rate from 8% in 2000 to 41% in 2019. This remarkable fivefold increase can be attributed to the country's overall development, including investment in education (particularly for girls) and reduction in child marriage, as well as the adoption and implementation of several enabling FP policies and strategies. In Ethiopia, achieving universal access to sexual and reproductive health care services, information, and education, including FP, by 2030 means enhancing these effective government policies and programs. Achieving universal access requires increasing financial resources, including domestic financing through greater government commitment for commodity security and program implementation; strengthening public-private partnerships; and improving service delivery for populations that are hard to reach and/or in humanitarian crisis. The persistence of equity gaps due to regional and/or sociodemographic disparities and the low quality of FP service delivery challenge our progress in Ethiopia. The papers included in this supplement provide additional detail on the overall progress described in this commentary and highlight focal areas for improvement in responding to unmet needs. Current policies and services must adapt, maintain, and build upon these gains and focus on targeted actions in areas identified for improvement. We must sustain the hard-fought gains of the past decades and help shape the prosperous future we advocate for in our society by 2030 and beyond-Leaving No One Behind.

Experiences of midwives on Vscan limited obstetric ultrasound use: a qualitative exploratory study.

BACKGROUND: Ethiopia is a low-income country located in the horn of Africa's sub-Saharan region, with very high incidences of maternal and neonatal mortality. Quality antenatal care improves perinatal health outcomes. The USAID funded Transform: Primary Health Care Activity in collaboration with the Ministry of Health and GE Healthcare introduced Vscan limited obstetric ultrasound services in 120 health centers in Ethiopia. So far, the experiences and opinions of midwives on their use have not been explored and described within the local context. This study therefore aims to explore and describe the experiences and opinions of midwives on Vscan limited obstetric ultrasound services at health centers within Ethiopia. METHODS: An exploratory and descriptive qualitative study was conducted in Amhara, Oromia, and Southern Nations, Nationalities and Peoples' (SNNP) regions of Ethiopia. Twenty-four participants were selected through a purposeful sampling technique. In-depth individual interviews with trained midwives with practical hands-on limited obstetric ultrasound service provision experience were conducted. The thematic analysis was conducted manually. RESULTS: The qualitative data analysis on the experiences and opinions of midwives revealed three themes, namely: individual perception of self-efficacy, facilitators, and barriers of limited obstetric ultrasound services. The basic ultrasound training, which was unique in its organization and arrangement, prepared and built the self-efficacy of trainees in executing their expected competencies. Support of health systems and health managers in dedicating space, availing essential supplies, and assigning human resources emerged as facilitators of the initiated limited obstetric ultrasound services, whereas high workload on one or two ultrasound trained midwives, interruption of essential supplies like paper towels, gel, and alternative power sources were identified as barriers for limited ultrasound services. CONCLUSION: This study explored the experiences and opinions of midwives who were trained on the provision of limited obstetric ultrasound services and served the community in health centers in rural parts of Ethiopia. The results of this study revealed the positive impacts of the intervention on the perceived self-efficacy, facilitation, and breaking-down of barriers to obstetric ultrasound services. Before scaling-up limited obstetric ultrasound interventions, health managers should ensure and commit to availing essential supplies (e.g., paper towels, ultrasound gel, and large memory hard discs), arranging private rooms, and training other mid-level health professionals. In addition, improving pregnant women's literacy on the national schedule for ultrasound scanning services is recommended.

The interaction of healthcare service quality and community-based health insurance in Ethiopia.

Community-based health insurance (CBHI) as a demand-side intervention is presumed to drive improvements in health services quality, and the quality of health services is an important supple-side factor in motivating CBHI enrollment and retention. There is, however, limited evidence on this interaction. This study examined the interaction between quality of health services and CBHI enrollment and renewal. A mixed-method comparative study was conducted in four agrarian regions of Ethiopia. The study followed the Donabedian model to compare quality of health services in health centers located in woredas/districts that implemented CBHI with those that did not. Data was collected through facility assessments, client-exit interviews, and key informant interviews. In addition to manual thematic analysis of qualitative data, quantitative descriptive and inferential analyses were done using SPSS vs 25. The process related (composite index including provider-client interpersonal communication) and outcome related (client satisfaction) measures of service quality in CBHI woreda/districts differed significantly from non-CBHI woredas/districts, but there were no significant differences in overall measures of structural quality between the two. The study found better diagnostic test capacity, availability of tracer drugs, provider interpersonal communication, and service quality standards in CBHI woredas. A higher proportion of clients at CBHI health centers gave high ratings of overall satisfaction with services. Individual and household factors including family size, age, household health care-related expenditures, and educational status, played a more significant role in CBHI enrollment and renewal decisions than health service quality. Key-informants reported in interviews that participation in the scheme increased accountability of health facilities in CBHI woredas/districts, because they promised to provide quality services using the CBHI premium collected at the beginning of the year from all enrolled households. This study indicates a need for follow-up research to understand the nuanced linkages between quality of care and CBHI enrollment.

Accelerating the performance of district health systems towards achieving UHC via twinning partnerships.

BACKGROUND: A twinning partnership is a formal and substantive collaboration between two districts to improve their performance in providing primary healthcare services. The 'win-win' twinning partnership pairs are categorized under relatively high and low-performing districts. The purpose of this formative evaluation is to use the empirically derived systems model as an analytical framework to systematically document the inputs, throughputs and outputs of the twinning partnership strategy. METHODS: This explanatory sequential mixed method study design was conducted from October 2018 to September 2019, in Amhara, Oromia, Southern, Nations, Nationalities and Peoples' (SNNP) and Tigray regions. The quantitative research approach used an observational design which consists of three measurements: at baseline (October 2018), midterm (March 2019) and end-line (September 2019), and the qualitative approach employed a case study. Qualitative data was collected using interviewer-guided semi-structured interview tools. The data were transcribed verbatim, translated from Amharic and Afan Oromo into English and analyzed through a theoretical framework named the Bergen Model of Collaborative Functioning (BMCF). Quantitative data were extracted from routine health management information system. The results are presented as averages, percentages and graphs. To claim statistical significance, non-parametric tests: Friedman test at (p < 0.05) and Wilcoxon signed ranks test (p < 0.017) were analyzed. RESULTS: The District Health System Performance (DHSP) was determined using data collected from eight districts. At baseline, the mean DHSP score was 50.97, at midterm, it was 60.3 and at end-line, it was 72.07. There was a strong degree and statistically significant relationship between baseline, midterm and end-line DHSP scores (r > 0.978**), using the Friedman test χ2(2) = 16.000, p = 0.001. Post hoc analysis using Wilcoxon signed-rank test was conducted with a Bonferroni correction and the results elicit higher DHSP values from baseline to midterm and from midterm to end-line with significance level set at p < 0.017. The qualitative results of the case study revealed that scanning the mission of the twinning partnership and focusing on a shared vision coupled with mobilizing internal and external resources were the fundamental input elements for successful twinning partnerships at the district level. In addition, the context of pursuing Universal Health Coverage (UHC) through achieving transformed districts can be enhanced through deploying skilled and knowledgeable leadership, defining clear roles and responsibilities for all stakeholders, forming agreed detailed action plans, and effective communication that leads to additive results and synergy. The twinning partnership implementing districts benefit from the formal relationship and accelerate their performances towards meeting the criteria of transformed districts in Ethiopia. CONCLUSIONS: Twinning partnerships help to accelerate the health system's performance in achieving the district transformation criteria. Therefore, scaling up the implementation of the twinning partnership strategy is recommended.

Does frequency of supportive supervisory visits influence health service delivery?-Dose and response study.

High quality care-at a minimum-is a combination of the availability of tangible resources as well as a capable and motivated health workforce. Researchers have suggested that supportive supervision can increase both the performance and motivation of health workers and the quality of care. This study is aimed at assessing the required number of visits and time between visits to bring about improvements in health service delivery. The study employed a primary health care performance improvement conceptual framework which depicts building blocks for improved health service delivery using longitudinal program outcome monitoring data collected from July 2017 to December 2019. The analysis presented in this study is based on 3,080 visits made to 1,479 health centers in the USAID Transform: Primary Health Care project's intervention districts. To assess the effects of the visits on the repeated measure of the outcome variable (Service-Delivery), multilevel linear mixed model (LMM) with maximum likelihood (ML) estimation was employed. The results showed that there was a significant dose-response relationship that consistent and significant improvement on Service-Delivery indicator was observed from first (ß = -26.07, t = -7.43, p < 0.001) to second (ß = -21.17, t = -6.00, p < 0.01), third (ß = -15.20, t = -4.49, p < 0.02), fourth (ß = -12.35, t = -3.58, p < 0.04) and fifth (ß = -11.18, t = -2.86, p < 0.03) visits. The incremental effect of the visits was not significant from fifth visit to the sixth suggesting five visits are the optimal number of visits to improve service delivery at the health center level. The time interval between visits also suggested visits made between 6 to 9 months (ß = -2.86, t = -2.56, p < 0.01) showed more significant contributions. Therefore, we can conclude that five visits each separated by 6 to 9 months elicits a significant service delivery improvement at health centers.