Measuring people's views on health system performance: Design and development of the People's Voice Survey.

Todd Lewis and co-authors discuss development and use of the People's Voice Survey for health system assessment.

Preeclampsia and eclampsia: Its burden and distribution across facilities in Ethiopia.

BACKGROUND: This study aimed to analyse national health facility burden of preeclampsia/eclampsia and its regional distribution in Ethiopia. This evidence is an important aspect to work towards reducing maternal and newborn complications. METHODS: This study uses data from the 2016 Emergency Obstetrics and Newborn Care (EmONC) survey which national census of public and private health facilities that provided delivery services. Cross-tabulation of variables was conducted based on region, location, types of health facility, and the management authority of health facilities. Spatial analysis was conducted to investigate spatial regional distribution of preeclampsia/eclampsia. RESULTS: A total of 3804 health facilities were included in the survey. Nationally, preeclampsia/eclampsia contributes to 5.9% of all maternal complications and 10.5% of maternal deaths. While 82% of total deliveries were reported from health centres, hospitals and specialised centres reported nearly 10 times more cases of PE/E (23 per 1000 deliveries) than health centres (2.4 per l000 deliveries). The highest number of preeclampsia/eclampsia cases were reported in Addis Ababa and the Harari region where there were 32 and 24 cases per 1000 deliveries, respectively. A substantial proportion of direct obstetrics complications due to preeclampsia/eclampsia were reported from Afar, Somali, Harari and the Benishangul Gumuz regions (19.9%, 18.0%, 12.8%. 11.5%, respectively). CONCLUSIONS: Preeclampsia/eclampsia contributed to a high proportion of maternal complications and death. Disproportionally, the highest burden of preeclampsia/eclampsia was reported in developing regions of Ethiopia. These region's health facilities'effort on case detection, reporting and evidence generation should be strengthened to inform policy especially those located in rural location.

Health Care Readiness in Management of Preeclampsia/Eclampsia in Ethiopia: Evidence from National Facility-Based Survey.

Background: Early case detection, treatment, and timely referral for better services can significantly reduce the negative outcomes of preeclampsia and eclampsia. However, evidence on health facilities' readiness to provide such services and the associated challenges is limited in Ethiopia. Therefore, this study aimed to assess the readiness of Ethiopian health care facilities to manage preeclampsia and eclampsia. Methods: This study used the 2016 Ethiopia national emergency management of obstetrics and newborn care (EmONC) survey. This survey was a national cross-sectional census of health facilities that provided delivery services. Data on facility infrastructure, equipment and supplies were collected through a facility checklist, and interview health provider experiences. Cross tabulation, summarisation and chi square tests by facility type, location, and management authority were conducted. Results: There were 3804 health facilities included in the survey across all regions of Ethiopia. The majority of facilities (92%) were public/government managed with only 1% of available hospitals located in rural areas. Poor availability of dipsticks for proteinuria tests (55.3%), caesarean sections (7.9%), and ambulance services (18.4%) were reported across health facilities with high variations in terms of facility type, location, and type of managing authority. Diazepam was a widely available anticonvulsant compared with magnesium sulfate (MgSO4), with more available in private for-profit facilities compared with public facilities. Nearly one third of health care providers were not trained to administer MgSO4 intravenously. The result indicated that the chi-square test was statistically significant at P < 0.001. Conclusions and Recommendations: There were notable gaps in readiness of facilities in detection and management of preeclampsia/eclampsia that increase maternal and perinatal mortality in Ethiopia. Therefore, availability of essential supplies, medications, and referrals are required. In addition, refresher training to healthcare providers on screening, diagnosis and management of preeclampsia/eclampsia and continuous supervision should be provided.

Audit of Clinical Care for Women with Preeclampsia or Eclampsia and Perinatal Outcome in Ethiopia: Second National EmONC Survey.

BACKGROUND: Preeclampsia and eclampsia contribute to maternal and perinatal morbidity and mortality, especially in developing countries. However, the evidence on clinical practice in the management of preeclampsia/eclampsia and perinatal outcomes is limited. Therefore, the aim of this study was to assess clinical care and perinatal outcomes for women with preeclampsia/eclampsia admitted to health facilities in Ethiopia. METHODS: This study used the 2016 Emergency Obstetric and Newborn Care survey, which included 3804 health facilities. The last two cases of women with preeclampsia/eclampsia who were admitted for birth in each participating health facility were selected and their medical records were reviewed. Descriptive analyses by health facility type, location and management authority were conducted. A chi-squared test was used to test for differences. RESULTS: Out of the 3804 health-care facilities across the country, we could review a total of 959 medical records of women with preeclampsia or eclampsia. Of all cases, 90% (863) were hospitalised in public health facilities, 542 (56.6%) were admitted at health centre/clinics and 638 (66.3%) were in urban health facilities. A substantial proportion of maternal and newborn information was missing from their medical records. Of the 553 records that recorded perinatal outcomes, the proportion of perinatal mortality prior to discharge was 16.3% (95% CI: 13.4%, 19.6%). A significant perinatal death was recorded among mothers admitted to hospitals (P < 0.01), maternal age 15-24 (P < 0.04), facilities in urban areas (P < 0.01), referred cases (P < 0.007), high systolic and diastolic blood pressure (P < 0.001), unconscious and experience seizure (P < 0.001), newborn with morbidity (P < 0.001), and women who spent more hours before giving birth (P < 0.002). CONCLUSIONS AND RECOMMENDATIONS: High perinatal mortality in health facilities was reported and care toward mothers with preeclampsia/eclampsia was limited. Strengthening the health facility readiness to respond for management with data registration and reporting system needs to be improved for evidence-based decision-making on perinatal and maternal health.

Exploring data quality and use of the routine health information system in Ethiopia: a mixed-methods study.

OBJECTIVE: A routine health information system (RHIS) enables decision making in the healthcare system. We aimed to analyse data quality at the district and regional level and explore factors and perceptions affecting the quality and use of routine data. DESIGN: This was a mixed-methods study. We used the WHO toolkit for analysing data quality and interviewed staff at the point of data generation and along with the flow of data. Data were analysed using the Performance of Routine Information System Management framework. SETTING: This study was performed in eight districts in four regions of Ethiopia. The study was nested within a 2-year programme of the Operational Research and Coaching for government Analysts. PARTICIPANTS: We visited 45 health posts, 1 district hospital, 16 health centres and 8 district offices for analysis of routine RHIS data and interviewed 117 staff members for the qualitative assessment. OUTCOME MEASURES: We assessed availability of source documents, completeness, timeliness and accuracy of reporting of routine data, and explored data quality and use perceptions. RESULTS: There was variable quality of both indicator and data element. Data on maternal health and immunisation were of higher quality than data on child nutrition. Issues ranged from simple organisational factors, such as availability of register books, to intricate technical issues, like complexity of indicators and choice of denominators based on population estimates. Respondents showed knowledge of the reporting procedures, but also demonstrated limited skills, lack of supportive supervision and reporting to please the next level. We saw limited examples of the use of data by the staff who were responsible for data reporting. CONCLUSION: We identified important organisational, technical, behavioural and process factors that need further attention to improve the quality and use of RHIS data in Ethiopia.

Routine health management information system data in Ethiopia: consistency, trends, and challenges.

Background: Ethiopia is investing in the routine Health Management Information System. Improved routine data are needed for decision-making in the health sector. Objective: To analyse the quality of the routine Health Management Information System data and triangulate with other sources, such as the Demographic and Health Surveys. Methods: We analysed national Health Management Information System data on 19 indicators of maternal health, neonatal survival, immunization, child nutrition, malaria, and tuberculosis over the 2012-2018 time period. The analyses were conducted by 38 analysts from the Ministry of Health, Ethiopia, and two government agencies who participated in the Operational Research and Coaching for Analysts (ORCA) project between June 2018 and June 2020. Using a World Health Organization Data Quality Review toolkit, we assessed indicator definitions, completeness, internal consistency over time and between related indicators, and external consistency compared with other data sources. Results: Several services reported coverage of above 100%. For many indicators, denominators were based on poor-quality population data estimates. Data on individual vaccinations had relatively good internal consistency. In contrast, there was low external consistency for data on fully vaccinated children, with the routine Health Management Information System showing 89% coverage but the Demographic and Health Survey estimate at 39%. Maternal health indicators displayed increasing coverage over time. Indicators on child nutrition, malaria, and tuberculosis were less consistent. Data on neonatal mortality were incomplete and operationalised as mortality on day 0-6. Our comparisons with survey and population projections indicated that one in eight early neonatal deaths were reported in the routine Health Management Information System. Data quality varied between regions. Conclusions: The quality of routine data gathered in the health system needs further attention. We suggest regular triangulation with data from other sources. We recommend addressing the denominator issues, reducing the complexity of indicators, and aligning indicators to international definitions.

Status of institutional-level respectful maternity care: Results from the national Ethiopia EmONC assessment.

OBJECTIVE: To assess the availability of an institutional-level respectful maternity care (RMC) index, its components, and associated factors. METHODS: A cross-sectional study design was applied to a 2016 census of 3804 health facilities in Ethiopia. The availability of an institutional-level RMC index was computed as the availability of all nine items identified as important aspects of institutional-level RMC during childbirth. Logistic regression analysis was used to identify factors associated with availability of the index. RESULTS: Three components of the institutional-level RMC index were identified: "RMC policy," "RMC experience," and "facility for provision of RMC." Overall, 28% of facilities (hospitals, 29.9%; health centers, 27.8%) reported availability of the institutional-level RMC index. Facility location urbanization (urban region), percentage of maternal and newborn health workers trained in basic emergency obstetric and newborn care, and availability of maternity waiting homes in health facilities were positively associated with availability of the institutional-level RMC index. CONCLUSION: Only one in three facilities reported availability of the institutional-level RMC index. The Ethiopian government should consider strengthening support mechanisms in different administrative regions (urban, pastoralist, and agrarian), implementing the provision training for health workers that incorporates RMC components, and increasing the availability of maternity waiting homes.

Association between maternal mortality and caesarean section in Ethiopia: a national cross-sectional study.

BACKGROUND: Several studies concluded that there is a reduction of maternal deaths with improved access to caesarean section, while other studies showed the existence of a direct association between the two variables. In Ethiopia, literature about the association between maternal mortality and caesarean section is scarce. This study was aimed to assess the association between maternal mortality ratios and caesarean section rates in hospitals in Ethiopia. METHODS: Analysis was done of a national maternal health dataset of 293 hospitals that accessed from the Ethiopian Public Health Institute. Hospital specific characteristics, maternal mortality ratios and caesarean section rates were described. Pearson's correlation coefficient was used to determine the direction of association between maternal mortality ratios and caesarean section rate, taking regions into consideration. Presence of a linear association between these variables was declared statistically significant at p-value < 0.05. RESULTS: The overall maternal mortality ratio in Ethiopian hospitals was 149 (95% CI: 136-162) per 100,000 livebirths. There was significant regional variation in maternal mortality ratios, ranging from 74 (95% CI: 51-104) per 100,000 livebirths in Tigray region to 548 (95% CI: 251-1,037) in Afar region. The average annual caesarean section rate in hospitals was 20.3% (95% CI: 20.2-20.5). The highest caesarean section rate of 38.5% (95% CI: 38.1-38.9) was observed in Addis Ababa, while the lowest rate of 5.7% (95% CI: 5.2-6.2) occurred in Somali region. At national level, a statistically non-significant inverse association was observed between maternal mortality ratios and caesarean section rates. Similarly, unlike in other regions, there were inverse associations between maternal mortality ratios and caesarean section rates in Addis Ababa, Afar Oromia and Somali, although associations were not statistically significant. CONCLUSIONS: At national level, a statistically non-significant inverse association was observed between maternal mortality ratios and caesarean section rates in hospitals, although there were regional variations. Additional studies with a stronger design should be conducted to assess the association between population-based maternal mortality ratios and caesarean section rates.

Perceptions of midwives on the quality of emergency obstetric care at hospitals in Ethiopia: A qualitative explanatory study.

BACKGROUND: In Ethiopia, maternal mortality remains an important public health concern. High maternal mortality is attributed in part to the poor quality of obstetric care. This study was designed to investigate perceptions of midwives about the quality of emergency obstetric care provided at hospitals in the Harari region of Ethiopia. METHODS: An explanatory qualitative study was conducted from December 2018 to February 2019 at public and private hospitals in the Harari region, Ethiopia. The data were obtained through in-depth interviews with 12 midwives working in maternity units. The interviewers took notes and audio-recorded the respondents' descriptions. Braun and Clarke's thematic analysis method was employed to analyse the data using Nvivo 12 qualitative data analysis software. RESULTS: Poorly designed infrastructure, including a scarcity of beds, rooms and ambulances challenged the provision of quality obstetric services. Midwives working at hospitals were inadequate in number and training opportunities were scarce. Language barriers affected effective communication between patients and caregivers. Frequent disruptions to medical supplies resulted in the provision of suboptimal obstetric care as it created an inability to provide appropriate medications. A lack of treatment protocols, poor supportive supervision, and poor staff motivation impaired the provision of quality obstetric care at hospitals, although disparities were observed among hospitals in this regard. CONCLUSIONS: Several interdependent factors limited the quality of emergency obstetric care at hospitals in the region. Quality improvement initiatives and equitable resource distribution for hospitals need to be enhanced while the existing health infrastructure, resources and service delivery management need to be strengthened.

Magnitude and determinants of obstetric case fatality rate among women with the direct causes of maternal deaths in Ethiopia: a national cross sectional study.

BACKGROUND: In sub-Saharan Africa, maternal death due to direct obstetric complications remains an important health threat for women. A high direct obstetric case fatality rate indicates a poor quality of obstetric care. Therefore, this study was aimed at assessing the magnitude and determinants of the direct obstetric case fatality rate among women admitted to hospitals with direct maternal complications. METHODS: In 2015, the Ethiopian Public Health Institute conducted a national survey about emergency obstetric and newborn care in which data about maternal and neonatal health indicators were collected. Maternal health data from these large national dataset were analysed to address the objective of this study. Descriptive statistics were used to present hospital specific characteristics and the magnitude of direct obstetric case fatality rate. Logistic regression analysis was performed to examine determinants of the magnitude of direct obstetric case fatality rate and the degree of association was measured using an adjusted odds ratio with 95% confidence interval at p < 0.05. RESULTS: Overall, 335,054 deliveries were conducted at hospitals and 68,002 (20.3%) of these women experienced direct obstetric complications. Prolonged labour (23.4%) and hypertensive disorders (11.6%) were the two leading causes of obstetric complications. Among women who experienced direct obstetric complications, 435 died, resulting in the crude direct obstetric case fatality rate of 0.64% (95% CI: 0.58-0.70%). Hypertensive disorders (27.8%) and maternal haemorrhage (23.9%) were the two leading causes of maternal deaths. The direct obstetric case fatality rate varied considerably with the complications that occurred; highest in postpartum haemorrhage (2.88%) followed by ruptured uterus (2.71%). Considerable regional variations observed in the direct obstetric case fatality rate; ranged from 0.27% (95% CI: 0.20-0.37%) at Addis Ababa city to 3.82% (95% CI: 1.42-8.13%) at the Gambella region. Type of hospitals, managing authority and payment required for the service were significantly associated with the magnitude of direct obstetric case fatality rate. CONCLUSIONS: The high direct obstetric case fatality rate is an indication for poor quality of obstetric care. Considerable regional differences occurred with regard to the direct obstetric case fatality rate. Interventions should focus on quality improvement initiatives and equitable resource distribution to tackle the regional disparities.

Incidence of maternal near miss among women in labour admitted to hospitals in Ethiopia.

OBJECTIVES: To assess the incidence of maternal near miss and contributing factors among hospitals in Ethiopia. The study also assessed the ability of hospitals to provide signal functions of emergency obstetric care and its regional distribution. DESIGN: A national dataset accessed from the Ethiopian Public Health Institute were analysed to assess the incidence of maternal near miss and mortality index among women admitted to hospitals with obstetric complications. SETTING: Maternal health indicators including obstetric complications, maternal deaths and births conducted at all hospitals available in Ethiopia were included. MEASUREMENTS: The maternal near miss incidence ratio, which is the number of near miss cases per 1,000 live births, and the mortality index were presented descriptively. Chi-squared test at p value ≤ 0.05 was used to assess the presence of significant regional differences of the provision of signal functions of emergency obstetric care. RESULTS: In 2015, 78,195 women were admitted to hospitals with both the direct (68,002) and indirect (10,193) causes of maternal mortality. Of women who experienced the direct causes, 435 died which means there were 67,567 maternal near miss cases. In the same year, 323,824 live births were reported in hospitals, making the crude maternal near miss incidence ratio of 20.8% (9.1-38.8%) and mortality index of 0.64% (435/68,002) for the direct causes of maternal mortality. A significant regional variation was observed with regard to incidence of maternal near miss, mortality index and the provision of signal functions of emergency obstetric care. Administration of parenteral antibiotics was the most frequently practiced signal function of emergency obstetric care while blood transfusion was the least provided signal function. CONCLUSIONS: In Ethiopian hospitals, the incidence of maternal near miss was unacceptably high. A significant regional variation was detected with regard to maternal near miss incidence ratio, mortality index and the provision of signal functions of emergency obstetric care. The Ethiopian government needs to work on equitable resource distribution and quality improvement initiatives in order to close the detected regional variations. IMPLICATIONS FOR PRACTICE: The Ethiopian government needs to practice evidence-based maternal health strategies, including capacity building of the regional hospitals in order to improve the distribution of resources and quality of maternal health.

Factors associated with health care provider knowledge on abortion care in Ethiopia, a further analysis on emergency obstetric and newborn care assessment 2016 data.

BACKGROUND: Abortion is one of the major direct causes of maternal death, accounting for 7.9% globally. In Africa, 5.5 million women have unsafe abortions annually. Although maternal deaths due to complications of abortion have declined in Ethiopia, women still die from complications. Few studies have focused on providers' clinical knowledge. This study investigates the level of health workers' knowledge of comprehensive abortion care and its determinants in Ethiopia. METHODS: Data from the national emergency obstetric and newborn care (EmONC) assessment was used. A total of 3804 facilities that provided institutional deliveries in the 12 months before the assessment were included. Provider knowledge was assessed by interviewing a single provider from each facility. Criteria for selection included: having attended the largest number of deliveries in the last one or two months. A summary knowledge score was generated based on the responses to three knowledge questions related to immediate complications of unsafe abortion, how a woman should be clinically managed and what the counselling content should contain. The score was classified into two categories (< 50% and > =50%). Logistic regression was used to determine individual and facility-level factors associated with the summary knowledge score. RESULT: A total of 3800 providers participated and the majority were midwives, nurses and health officers. On average, providers identified approximately half or fewer of the expected responses. The multivariate model showed that midwives and nurses (compared to health officers), being female, and absence of training or practice of manual vacuum aspiration were associated with lower knowledge levels. Important facility level factors protective against low knowledge levels included employment in Addis Ababa, being male and having internet access in the facility. CONCLUSION: To increase knowledge levels among providers, pre- and in-service training efforts should be particularly sensitive to female providers who scored lower, ensure that more midlevel providers are capable of performing manual vacuum aspiration as well as provide special attention to providers in the Gambella.