Women's preferences for obstetric care in rural Ethiopia: a population-based discrete choice experiment in a region with low rates of facility delivery.

BACKGROUND: Delivery attended by skilled professionals is essential to reducing maternal mortality. Although the facility delivery rate in Ethiopia's rural areas is extremely low, little is known about which health system characteristics most influence women's preferences for delivery services. In this study, women's preferences for attributes of health facilities for delivery in rural Ethiopia were investigated. METHODS: A population-based discrete choice experiment (DCE) was fielded in Gilgel Gibe, in southwest Ethiopia, among women with a delivery in the past 5 years. Women were asked to select a hypothetical health facility for future delivery from two facilities on a picture card. A hierarchical Bayesian procedure was used to estimate utilities associated with facility attributes: distance, type of provider, provider attitude, drugs and medical equipment, transport and cost. RESULTS: 1006 women completed 8045 DCE choice tasks. Among them, 93.8% had delivered their last child at home. The attributes with the greatest influence on the overall utility of a health facility for delivery were availability of drugs and equipment (mean ß=3.9, p<0.01), seeing a doctor versus a health extension worker (mean ß=2.1, p<0.01) and a receptive provider attitude (mean ß=1.4, p<0.01). CONCLUSION: Women in rural southwest Ethiopia who have limited personal experience with facility delivery nonetheless value health facility attributes that indicate high technical quality: availability of drugs and equipment and physician providers. Well-designed policy experiments that measure the contribution of quality improvements to facility delivery rates in Ethiopia and other countries with low health service utilisation and high maternal mortality may inform national efforts to reduce maternal mortality.

Food insecurity, stressful life events and symptoms of anxiety and depression in east Africa: evidence from the Gilgel Gibe growth and development study.

OBJECTIVES: Common mental disorders are a major contributor to the burden of disease in developing countries. An assessment was carried out of whether food insecurity and exposure to stressful life events, two common features of life in sub-Saharan Africa (SSA), are associated with symptoms of mental disorders among adults. METHODS: The Gilgel Gibe Growth and Development Study (GGGDS) is an ongoing cohort study in rural Ethiopia. Participants of the GGGDS were randomly selected from households from a complete census of persons living in the area. The Hopkins Symptom Checklist and the Harvard Trauma Questionnaire were used to assess anxiety and depression and post-traumatic stress symptoms. RESULTS: Among 902 adult participants, food insecurity, stressful life events and symptoms of common mental disorders were highly prevalent. In separate multivariate models adjusting for potential confounders, food insecurity and stressful life events were independently associated with high symptoms of depression, anxiety and post-traumatic stress. CONCLUSIONS: Potentially modifiable stressors may influence variation in common mental disorders in Ethiopia, and SSA more generally. These findings suggest that the negative effects of food insecurity extend beyond nutritional outcomes and that interventions that promote food security may also positively influence adult mental health in the region.

Malnutrition and mental development: is there a sensitive period? A nested case-control study.

To examine the possibility that there is an early sensitive period for the effects of malnutrition on cognitive development, three groups of children (N = 197) were recruited from a birth cohort with known growth characteristics in south-west Ethiopia (N = 1,563). All had initial weights > or = 2,500 g. Early growth falterers dropped in weight below the third centile (z < -1.88) of the NCHS/WHO reference population in the first 4 months. Late growth falterers were children not in the first group whose weights were below the third centile at 10 and 12 months. Controls were a stratified random sample with weights above the third centile throughout the first year. All children were tested blind at 2 years using the Bayley Scales of Infant Development, adapted for use in Ethiopia. Mean (SD) scores on the psychomotor scale were 10.2 (3.7) in the controls, 6.6 (4.2) in the early growth falterers, and 8.5 (4.3) in the late growth falterers. For the mental scale they were 28.9 (5.8), 22.6 (6.2), and 26.6 (6.1) respectively. Both overall differences were statistically significant at p < .001, and planned comparisons between the control and the combined growth faltering groups, and between the early and later growth faltering groups, showed that each difference was statistically significant for both scales. However, early weight faltering was associated with weight at the time of testing (r = .33), which was associated with scores both on the psychomotor (r = .53) and the mental scale (r = .49). After taking weight at the time of testing into account there was no additional effect attributable to the timing of growth faltering. In this population, therefore, early malnutrition does not have specific adverse effect beyond the contribution that it makes to enduring malnutrition over the first 2 years.

Assessing the goodness-of-fit of the Laird and Ware model--an example: the Jimma Infant Survival Differential Longitudinal Study.

The Jimma Infant Survival Differential Longitudinal Study is an Ethiopian study, set up to establish risk factors affecting infant survival and to investigate socio-economic, maternal and infant-rearing factors that contribute most to the child's early survival. Here, a subgroup of about 1500 children born in Jimma town is examined for their first year's weight gain. Of special interest is the impact of certain cultural practices like uvulectomy, milk teeth extraction and butter swallowing, on child's weight gain; these have never been thoroughly investigated in any study. In this context, the linear mixed model (Laird and Ware) is employed. The purpose of this paper is to illustrate the practical issues when constructing the longitudinal model. Recently developed diagnostics will be used herefor. Finally, special attention will be paid to the two-stage interpretation of the linear mixed model.

Traditional nutritional and surgical practices and their effects on the growth of infants in south-west Ethiopia.

A 1-year birth cohort of 1563 infants was seen bi-monthly for the first year of life. They comprised all identified infants born in Jimma town, south-west Ethiopia, in the year starting 1 Meskren 1985 in the Ethiopian calendar (11 September 1992). Growth in infancy is poor in this town, as it is in Ethiopia more generally: mean z-scores for both weight and length were more than 1.5 SD below the median of the NCHS/WHO reference population by 1 year of age, and infant mortality was 115/1000. In this paper we examine the weight gain of singletons in relation to background variables and to traditional nutritional and surgical practices in the families. Confirming work in other areas, sanitation, water supply, the income of the family and the mother's literacy were important determinants of weight gain. Almost all the infants were initially breast fed, and about 80% were still breast fed at 1 year. Many were also given cows' milk from 4 months onwards. Breast feeding had beneficial effects up to 8 months of age, and cows' milk had beneficial effects after 6 months of age. Supplementary feeds of solids and semi-solids were given at appropriate ages, but had no detectable benefit. Water was given inappropriately early, but did no detectable harm. Episodes of diarrhoea, fever or persistent cough each reduced weight gain. Catch-up in weight then took up to 8 months, probably because of the poor nutritional quality of supplementary feeds. The incidences of local traditional operations in the first year were: circumcision 63% in males and 4% in females, uvulectomy 35% and the extraction of milk teeth 38%. Although circumcision had no detectable adverse effect on weight, uvulectomy and milk teeth extraction both reduced weight gain.

PIP: The effect of family-level activities on growth in infancy was examined by looking into traditional nutritional and surgical practices in Ethiopia. The subjects were 1563 infants born in Jimma, southwest Ethiopia between 11 September 1992 and 10 September 1993. Prior to birth, pregnant women were identified through a network of traditional birth attendants (TBAs). The TBAs worked closely with the project interviewer in gathering information from pregnancy until birth. Details of the sample size at different ages, of the actual ages at which infants were weighed and of known deaths are presented. It was found that the level of infants' weight gain over the first year was related to environmental and familial background. Environmental factors cited include sanitation and water supply. Family income and the level of the mother's literacy were important determinants of weight gain. A big majority of the infants were initially breast-fed, and about 80% were still breast-fed at 1 year. Infant nutrition was supplemented by cow's milk from 4 months onward. In addition, supplementary feedings of solid and semisolid foods were given at appropriate ages, but had no evident benefit. Ailments such as diarrhea, fever and persistent cough slowed down growth, but eventually weight increased at age 8 months. Local traditional operations such as uvulectomy and extraction of milk teeth in the first year also contributed to the reduction of weight gain, but circumcision in either males or females had no detectable adverse effect on weight.

An Ethiopian birth cohort study.

A one-year birth cohort was studied in Jimma town, South West Ethiopia, in 1992-93. We report here on the design and on the methods used in the study and describe the principal health outcomes. Infants were visited bimonthly until their first birthday. Background data on the physical, cultural and economic environment of the home were collected at the first visit, and data on nursing and weaning on traditional surgical and other practices, and on vaccination at the first visit and at each subsequent visit. Length, weight and mid upper arm circumference were measured, and details of the mother's handling of illness episodes recorded. Of 1563 children born, 86% were successfully followed to the end of their first year or to an earlier death. There were 141 deaths, indicating an infant mortality of 115/1000 (estimated probability of surviving to 1 year 0.8851, with s.e. 0.0101). The mean length and weight of the singleton infants at the end of their first year was -1.41 and -1.52 SD from the median of the NCHS/WHO reference population. Weights throughout the first year were analysed in more detail using a Reed model, fitted as a random coefficient regression model in ML3-E. There were clear differences in growth across the different ethnic groups, with the best growing group weighing on average about 1 kg more at the end of the first year than the groups growing least well.

Risk behaviors for HIV infection: their occurrence and determinants in Jima-Town, southwestern Ethiopia.

Little is known about the occurrence of high risk behaviours for HIV infection among the general population of Ethiopia. With this in mind, 495 randomly selected males between 15 and 49 years of age were questioned about specific risk behaviours. From this interview a total and sex risk behaviour score were calculated and then analysed for their association with sociodemographic factors and knowledge and attitudes about AIDS. This investigation was carried out in the fall of of 1988 in Jima-Town, southwestern Ethiopia. Several high risk behaviours were found to be highly prevalent; 47.2% reported a history of sex with prostitutes (18% in the past month), and 39% reported receiving injections in the past year. Higher risk scores were significantly associated with high knowledge about AIDS and among skilled labourers and those between 25 to 34 years of age.