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.

Adherence of healthcare providers to malaria case management guidelines of the formal private sector in north-western Ethiopia: an implication for malaria control and elimination.

BACKGROUND: Malaria is an infectious disease which has been globally targeted for elimination in at least 35 of 90 endemic countries by 2030. Most successful malaria elimination country programmes have engaged the private health sector in an effort to identify, document, investigate, provide effective treatment, and follow-up cases. However, there has been limited rigorous research showing evidence of adherence among healthcare providers of the formal private health sector to national malaria diagnosis and treatment guidelines in Ethiopia, starting from malaria control to elimination phases. The aims of this study were to investigate and explain the level of adherence to malaria diagnosis and treatment guidelines among healthcare providers working in formal private health facilities in north-western Ethiopia. METHODS: An explanatory sequential mixed method design was conducted in the West Gojjam Zone of Ethiopia. Quantitative data were extracted from 1650 medical records of adult uncomplicated malaria outpatients served in 11 private-for-profit health facilities. In addition, using a qualitative approach, 33 in-depth interviews (IDIs) with healthcare providers were conducted. All interviews were audio-recorded, transcribed verbatim, and analysed using eight steps. RESULTS: Of 1650 suspected malaria cases in adult outpatients, 80.6% (1330/1650) were screen tested using microscopy and the remainder 19.4% (320/1650) were tested using multispecies rapid diagnosis tests (RDTs). Hence, the results revealed that private healthcare providers universally adhered to diagnosis guidelines. In addition, after following-up and excluding other causes of fever, 4.1% (56/1376) patients were clinically diagnosed with uncomplicated malaria. Despite this, the proportion of private healthcare provider adherence with confirmed malaria case treatment guidelines was 20.9% (69/330). In addition, 1320 (95.9%) of adult outpatients with negative laboratory results were not treated. Some of the identified determinant factors for sub-optimal adherence of healthcare providers to malaria guidelines were interruptions in supply and lack of availability of recommended anti-malarial drugs, lack of availability of quality assured laboratory supplies, and poor knowledge of the recommendations of the national standards. CONCLUSIONS: Private healthcare providers adhered to universal parasitological diagnosis, providing comprehensive counseling, and linking patients with community health workers. In addition, almost all laboratory negative patients were not treated with anti-malarial drugs. However, only one-fifth of confirmed patients were treated in line with national guideline recommendations. Malaria control and elimination efforts across Ethiopia could be improved through establishing a collaborative function of a win-win public private mix partnership model. In addition, including the data of the private health sector in the health information system could show real malaria burden and use the information to improve the adherence to malaria diagnosis, treatment, and reporting standards within the targeted era of elimination. Therefore, building the capacity of private healthcare providers and ensuring the availability of all nationally recommended drugs and supplies in private health sector facilities is recommended to improve the quality of services.

Exploring the opportunities and challenges of female health leaders in three regional states of Ethiopia: a phenomenological study.

BACKGROUND: Gender equity involves fairness in all aspects of life for women and men and is usually determined by social, political, economic, and cultural contexts. The proportion of female leaders in healthcare within the health sector is low. The aim of this study was to explore and describe the experiences, opportunities, and challenges faced by women in their path towards becoming leaders within the health sector. METHODS: This study was conducted using the phenomenological method of qualitative inquiry. The approach was chosen for its merits to narratively explore and describe the lived stories and shared experiences of women leaders in the healthcare system. A purposive sampling technique was used to identify six women leaders. Semi-structured interviews were conducted through telephone by the investigators. The qualitative data analysis was conducted parallel with data collection, using steps of thematic analysis. RESULTS: This study identified individual, societal, and organizational level opportunities and challenges that had an influence on the career paths of female health leaders in Ethiopia. The leadership positions were an opportunity in the career development of women who had long-term goals, were known for their empathy, and exercised wise use of resources. In addition, women who had the support of close family members and their peers are more likely to compete and rise to leadership positions. Furthermore, women who received organizational support in the form of affirmative action, training, development, and recognition also tended to rise to leadership positions. However, women who assumed leadership positions but whose day-to-day decision-making was influenced by their supervisors, those who had experienced sexual harassment, and those under the influence of societal norms were less likely to attain leadership positions. CONCLUSION: The opinions and experiences of female health leaders revealed that individual behaiour whileassumming a leadership positon, empathy, and wise resource management positivey influence their career development. In addition, female health workers who had support form close family members and peers strived for growth to leadership positions. Furthermore, the presence of organizational support, in the form of affirmative actions, and succession planning were another opportunity for females in their career paths. Conversely, some social norms were found to deter female health workers from advanicing to leadership positions. Therefore, enhancing the leadership capacity of women and improving social and organizational support is recommended. In addition, addressing the low level of self-image among women and patriarchal societal norms at the community level is recommended.

Contribution of portable obstetric ultrasound service innovation in averting maternal and neonatal morbidities and mortalities at semi-urban health centers of Ethiopia: a retrospective facility-based study.

BACKGROUND: The maternal and neonatal mortalities in Ethiopia are high. To achieve the Sustainable Development Goals, innovations in ultrasound scanning and surveillance activities have been implemented at health centers for over 2 years. This study aims to estimate the contribution of obstetric ultrasound services on averted maternal and neonatal morbidities and mortalities in Ethiopia. METHODS: A retrospective facility-based cross-sectional study design was conducted in 25 selected health centers. Data were extracted from prenatal ultrasound registers. SPSS version 25 was used for analysis. To claim statistically significant relationship among sartorial variables, a chi-square test was analyzed and P < 0.05 was the cut-off point. RESULTS: Over the 2 years, 12,975 pregnant women were scanned and 52.8% of them were residing in rural areas. Abnormal ultrasound was reported in 12.7% and 98.4% of them were referred for confirmation of diagnosis and treatment. The ultrasound service has contributed to the prevention of 1,970 maternal and 19.05 neonatal morbidities and mortalities per 100,000 and 1,000 live births respectively. The averted morbidities and mortalities showed a statistically significant difference among women residing in rural and semi-urban areas, X,2 df (10) = 24.07, P = 0. 007 and X,2 df (5) = 20.87. P = 0.00, 1 respectively. CONCLUSION: After availing the appropriate ultrasound machines with essential supplies and capacitating mid-level providers, significant number of high-risk pregnant women were identified on time and managed or referred to health facilities with safe delivery services. Therefore, scaling-up limited obstetric ultrasound services in similar setups will contribute to achieving the Sustainable Development Goals by 2030. It is recommended to enhance community awareness for improved utilization of ultrasound services by pregnant women before the 24th week of gestational age.

An evaluation of excellence in primary healthcare units after the introduction of a performance management innovation in two regional states of Ethiopia: a facility based comparative study.

BACKGROUND: The Ethiopian Ministry of Health strives to achieve universal health coverage (UHC) through increasing the number of its high-performing primary healthcare units. Although the Ethiopian health system is managed within a decentralized political system, the Ministry of Health works towards institutionalizing performance management innovations and organizational cultures that increase the excellence of primary healthcare entities. To date, there has been little evidence gathered on the factors influencing the excellence of primary healthcare units in Ethiopia. Therefore, the aim of this study was to assess and compare how the introduction of performance management and organizational culture innovations through project support affect the excellence of primary healthcare units in Ethiopia. METHODS: A facility-based comparative study was conducted in USAID Transform: Primary Health Care project supported and non-supported primary healthcare units located in the Oromia and Southern Nations Nationalities and Peoples' (SNNP) regions of Ethiopia. Quantitative data were collected from randomly selected health workers using interviewer-administered questionnaires. In addition, primary healthcare unit excellence measurements were extracted from routine health information databases over eight quarters. The data were analyzed using the Statistical Package for Social Science (SPSS IBM v 20) research software package. Results were presented in frequency tables and graphs. After checking the data for homogeneous distribution, a paired sample t-test for equal variances, otherwise known as the Mann-Whitney U test was analyzed to claim statistically significant difference at P < 0.05. RESULTS: Out of 368 invited health workers, 364 participated in this study, (a response rate of 98.9%). Slightly higher than two-thirds of participants were enrolled from the Jimma Zone of Oromia Region. Orientations on performance management standards were provided to 101 (68.2%) and 45 (48.3%) health workers from project-supported and non-supported facilities, respectively. The mean perceived organizational culture score with [± Standard Deviation (SD)] was 3.72 ± 0.75 among project-supported health workers and 3.385 ± 0.75 among non-supported health workers, respectively. An independent sample t-test showed statistically significant differences, where project-supported health workers had higher mean scores on perceived organizational culture than their non-supported counterparts, with t = 433, df = 362, P = 0.001. The mean baseline primary healthcare unit excellence score was 63.2% and 50.5% for project-supported and non-supported health facilities, respectively. The end line excellence scores increased to 93.3% for project-supported and 79.1% for non-supported facilities. The end line overall primary healthcare units' mean rank excellence scores were 257.67 for the project supported and 105.66 for non-project supported facilities. This result of a non-parametric test, i.e. the Mann-Whitney U test revealed that project-supported facilities were higher and had a positive statistically significant difference (U = 2,728, z = -13.78, P = 0.001). CONCLUSIONS: The findings of this study underscore a direct relationship between implementing performance management innovations and enhancing organizational cultures for excellence at primary healthcare units. Project-supported primary healthcare units had higher organizational culture and excellence scores than their counterpart non-supported facilities. Therefore, achieving UHC through excellence in primary healthcare facilities requires scaling up of performance management innovation interventions.

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.

Immunization data quality and decision making in pertussis outbreak management in southern Ethiopia: a cross sectional study.

BACKGROUND: The aim of this study was to investigate the quality of immunization data and monitoring systems in the Dara Malo District (Woreda) of the Gamo Administrative Zone, within the Southern Nations, Nationalities, and Peoples' Region (SNNPR) of Ethiopia. METHODS: A cross-sectional study was conducted from August 4 to September 27, 2019, in Dara Malo District. The district was purposively selected during the management of a pertussis outbreak, based on a hypothesis of 'there is no difference in reported and recounted immunization status of children 7 to 23 months in Dara Malo District of Ethiopia'. The study used the World Health Organization (WHO) recommended Data Quality Self-Assessment (DQS) tools. The accuracy ratio was determined using data from routine Expanded Program of Immunization (EPI) and household surveys. Facility data spanning the course of 336 months were abstracted from EPI registers, tally sheets, and monthly routine reports. In addition, household surveys collected data from caretakers, immunization cards, or oral reports. Trained DQS assessors collected the data to explore the quality of monitoring systems at health posts, health centers, and at the district health office level. A quality index (QI) and proportions of completeness, timeliness, and accuracy ratio of the first and third doses of pentavalent vaccines and the first dose of measles-containing vaccines (MCV) were formulated. RESULTS: In this study, facility data spanning 336 months were extracted. In addition, 595 children aged 7 to 23 months, with a response rate of 94.3% were assessed and compared for immunization status, using register and immunization cards or caretakers' oral reports through the household survey. At the district level, the proportion of the re-counted vaccination data on EPI registers for first dose pentavalent was 95.20%, three doses of pentavalent were 104.2% and the first dose of measles was 98.6%. However, the ratio of vaccination data compared using tallies against the reports showed evidence of overreporting with 50.8%, 45.1%, and 46.5% for first pentavalent, third pentavalent, and the first dose of measles vaccinations, respectively. The completeness of the third dose of pentavalent vaccinations was 95.3%, 95.6%, and 100.0% at health posts, health centers, and the district health office, respectively. The timeliness of the immunization reports was 56.5% and 64.6% at health posts and health centers, respectively, while the district health office does not have timely submitted on time to the next higher level for twelve months. The QI scores ranged between 61.0% and 80.5% for all five categories, namely, 73.0% for recording, 71.4% for archiving and reporting, 70.4% for demographic information, 69.7% for core outputs, and 70.4% for data use and were assessed as suboptimal at all levels. The district health office had an emergency preparedness plan. However, pertussis was not on the list of anticipated outbreaks. CONCLUSION: Immunization data completeness was found to be optimal. However, in the study area, the accuracy, consistency, timeliness, and quality of the monitoring system were found to be suboptimal. Therefore, poor data quality has led to incorrect decision making during the reported pertussis outbreak management. Availing essential supplies, including tally sheets, monitoring charts, and stock management tools, should be prioritized in Daro Malo District. Enhancing the capacity of healthcare providers on planning, recording, archiving, and reporting, analyzing, and using immunization data for evidence-based decision making is recommended. Improving the availability of recording and reporting tools is also likely to enhance the data accuracy and completeness of the community health information system. Adapting pertussis outbreak management guidelines and conducting regular data quality assessments with knowledge sharing events to all stakeholders is recommended.

Examining Governing Board Functions and Health Center Performances During Health System Reform: A Cross-sectional Study in 4 Regional States of Ethiopia.

BACKGROUND: Since 1995, the Ethiopian health system has been managed through decentralizing functions, resources, and authorities to local levels. As a result, health centers are led and managed by governing boards. In addition, the national health system strives to transform the performance of health centers through the implementation of reforms. Therefore, this study aims to examine the relationship between governing board functions and health center performances within a health reform context in 4 agrarian regions of Ethiopia. METHODS: A cross-sectional survey was conducted from August 28, 2018 to September 30, 2018. Primary data were collected from governing board chairpersons or their designees using interviewer-administered structured questionnaires. The performance of each health center was rated out of 100 percentage points against the Ethiopian Health Center Reform Guideline (EHCRIG) standards. Secondary data were abstracted from a routine health information database using customized tools to capture achievements on 69 EHCRIG standards and its 174 validation criteria. Since the data violate the assumptions of the parametric test, the Spearman's rank (rho) correlation test, (a non-parametric test) was employed to see if any correlation exists among 4 parameters; namely: structure, roles and responsibilities, training and development of governing boards, and performance of health centers against EHCRIGs standards. A statistically significant relationship was claimed at P<.050. RESULTS: All 83 health center governing boards or designees who were approached for this study, participated. The mean health center governing board function score with standard deviation was 56.0% (SD ± 14.5%). The overall performance of health centers against EHCRIGs was 70.4% (SD ± 15.0%). There was a statistically significant and strong correlation (Spearman rho correlation coefficient) between health center performance scores measured against reform standards with governing board scores of (rho=0.866, P<.001) and overall governance scores (rho=0.828, P<.001). CONCLUSION: Based on the results of this study, we can conclude that well-functioning health center governing boards can improve the performance of health centers against clinical, and management reform standards. Therefore, continuous strengthening of the capacity of governing boards, focusing on improving implementation of their roles and responsibilities, and continuing training on business management is recommended.

Comparison of maternal and child health service performances following a leadership, management, and governance intervention in Ethiopia: a propensity score matched analysis.

BACKGROUND: Leadership, management, and governance (LMG) interventions play a significant role in improving management systems, enhancing the work climate, and creating responsive health systems. Hence, the Ethiopian Ministry of Health with the support of the USAID Transform: Primary Health Care project has been implementing LMG interventions to improve performances of primary healthcare entities. The purpose of this evaluation was to compare maternal and child health service performances and overall health system strengthening measurement results of primary health care entities by LMG intervention exposed groups. METHODS: The study used a cross-sectional study design with a propensity matched score analysis, and was conducted from August 28, 2017, to September 30, 2018, in Amhara, Oromia, Tigray, and Southern Nations, Nationalities, and Peoples' (SNNP) regions. Data collection took place through interviewer and self-administered questionnaires among 227 LMG intervention exposed and 227 non-exposed health workers. Propensity score matched analysis was used to balance comparison groups with respect to measured covariates. RESULTS: The mean overall maternal and child health key performance indicator score with standard deviation (± SD) for the LMG intervention exposed group was 63.86 ± 13.16 and 57.02 ± 13.71 for the non-exposed group. The overall health system strengthening score for the LMG intervention exposed group (mean rank = 269.31) and non-exposed group (mean rank = 158.69) had statistically significant differences (U = 10.145, z = - 11.175, p = 0.001). In comparison with its counterpart, the LMG exposed group had higher average performances in 3.54, 3.51, 2.64, 3.00, 1.07, and 3.34 percentage-points for contraceptive acceptance rate, antenatal care, skilled birth attendance, postnatal care, full immunization, and growth monitoring services, respectively. CONCLUSION: There were evidences on the positive effects of the LMG intervention on increased maternal and child health services performances at primary healthcare entities. Moreover, health facilities with LMG intervention exposed health workers had higher and statistically significant differences in management systems, work climates, and readiness to face new challenges. Therefore, this study generated evidence for integrating LMG interventions to improve the performance of primary healthcare entities and maternal and child service uptake of community members, which contributes to the reduction of maternal and child deaths.

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.

Readiness of Primary Hospitals in Providing Neonatal Intensive Care Services in Ethiopia.

BACKGROUND: The Ethiopian neonatal mortality has not shown much progress over the years. In light of this, the country has introduced interventions such as the utilization of newborn corners and neonatal intensive care units to avert preventable neonatal deaths. This study was conducted to assess readiness of primary hospitals in providing neonatal intensive care services. METHODS: A health facility based cross-sectional study design was employed where data were collected using both prospective and retrospective techniques using a format adapted from national documents. SPSS version 25 was used for data entry and analysis using descriptive statistics. RESULTS: Data were collected from 107 of 113 (94.7%) primary hospitals due to inaccessibility of some primary hospitals. The minimum national standard requirement of a level one neonatal intensive care unit for infrastructure was met by 63% (68/107) and 44% (47/107) had fulfilled the requirements for kangaroo mother care units. The average number of neonatal intensive care unit trained nurses per primary hospital was 2.6, 0.8 for general practitioners and 2.9 support staff; all of which is less than the minimum recommended national standard. The minimum national requirement for medical equipment and renewables for primary hospital level was fulfilled by 24% (26/107) of the hospitals, 65% (70/107) for essential laboratory tests, and 87% (93/107) for clinical services and procedures. The average number of admissions during the six months prior to the data collection was 87.2 sick newborns per facility with a 'discharged improved' rate of 71.5%, referral out rate of 18.4% and level one neonatal intensive care unit death rate of 6.6%. The remaining newborns had either left against medical advice or were still undergoing treatment during data collection. CONCLUSIONS: The overall readiness of primary hospitals to deliver neonatal intensive care services in terms of infrastructure, human resource, medical equipment, and laboratory tests was found to be low. There is a need to fill gaps in infrastructure, medical equipment, renewables, human resource, laboratory reagents, drugs and other supplies of neonatal intensive care units of primary hospitals to garner better quality of service delivery.

Contributing barriers to loss to follow up from antenatal care services in villages around Addis Ababa: a qualitative study.

BACKGROUND: Problems during pregnancy, childbirth and postpartum are the major contributors to maternal and perinatal morbidity and mortality. Focused antenatal care is an intervention set to provide basic services for pregnant women, to reduce morbidity and mortality related to pregnancy. In Ethiopia, there is a significant loss to follow up from antenatal care services between the first and fourth visits. The aim of this study is to explore the potential contributing barriers to loss to follow up of pregnant women from antenatal care services in villages around Addis Ababa, the capital city of the country. METHODS: A qualitative research method was used, where 20 in-depth interviews (zonal, woreda and health center managers, midwives and health extension workers were the participants) and three focus group discussions (mothers who were lost to follow up, mothers who completed four sessions of antenatal care visits, and community volunteers were the participants) were conducted. A qualitative data analysis software, ATLAS.ti 8, was applied. RESULTS: Inability to deliver essential antenatal care services which occurs primarily due to shortage of the required medical equipment, drugs, and other supplies is a major barrier for sustainable attendance of antenatal care services followed by poor care, respect, and receptiveness of service providers. Lack and cost of transport as well as partners' approval and support were also claimed to be part of the major barriers. Community culture and pervious maternal experiences as well as maternal sociodemographic factors like maternal age at time of pregnancy and educational status of mothers were also reported as barriers to seeking and completion of antenatal care services. CONCLUSIONS: Both demand and supply side barriers play a significant role in the loss to follow up from antenatal care services. Availing essential antenatal care services, closer to the community by improving the infrastructure, health workforce and supply chain system is recommended.

Implementing a modified World Health Organization safe childbirth checklist in health centers of Ethiopia: a pre and post intervention study.

BACKGROUND: Childbirth is a complex process, and checklists are useful tools to remember steps of such complex processes. The World Health Organization safe childbirth checklist is a tool used to improve the quality of care provided to women giving birth. The checklist was modified by Ministry of Health and was introduced to health centers in Ethiopia by the USAID Transform: Primary Health Care Activity. METHODS: A pre and post intervention study design with prospective data collection was employed. The availability of essential childbirth supplies and adherence of health care providers to essential birth practices were compared for the pre and post intervention periods. RESULTS: The pre and post intervention assessments were conducted in 247 and 187 health centers respectively. A statistically significant improvement from 63.6% pre intervention to 83.5% post intervention was observed in the availability of essential childbirth supplies, t (389.7) = - 7.1, p = 0.000. Improvements in adherence of health care providers to essential birth practices were observed with the highest being at pause point three (26.2%, t (306.3) = - 10.6, p = 0.000) followed by pause point four (21.1%, t (282.5) = - 8.0, p = 0.000), and pause point two (18.2%, t (310.8) = - 9.7, p = 0.000). The least and statistically non-significant improvement was observed at pause point one (3.3%, t (432.0) = - 1.5, p = 0.131). CONCLUSION: Improvement in availability of essential childbirth supplies and adherence of health care providers towards essential birth practices was observed after introduction of a modified World Health Organization safe childbirth checklist. Scale up of the use of the checklist is recommended.

Removal of a missing intrauterine contraceptive device after location through an ultrasound: a case report within a rural setting and review of literature.

BACKGROUND: In the last decade, (2000-2019), the modern contraceptive prevalence among married women of reproductive age (14-49 years), has increased by only 2.1%. The slow progress was due to limited access to services and myths surrounding methods held by both users and providers. This case report was identified, diagnosed and managed by a midwife working in rural health center in low resource setting. However, literature is scare on the management of missing Intra-Uterine Contraceptive Device (IUCD) thread removal services of confirmed diagnosis using Vscan or limited ultrasound services in rural health centers. The aim of reporting this case report was developed to enhance easy access to intra-uterine contraceptive method removals, which may address myths associated with difficulties of undergoing the services in rural set-up. A 26 year-old married woman, Gravida 1 and Para 1, attended Mekoy Health Center for IUCD removal service after 7 years of protection and internally referred to limited obstetric ultrasound service room due to non- visualization of IUCD thread with Vaginal Speculum examination. An ultrasonography scan however, showed a centrally located copper-T 380A IUCD in the endometrial cavity. As a result, after dilatation of the cervix, a successful removal of the Copper-T 308A was conducted. The client received followed up care for 2 hours post-procedure and was then discharged. CONCLUSIONS: This case highlights the importance of availing diagnostic and removal services in rural set ups to mitigate myths in the community. The availability of limited obstetric ultrasound scanning services can improve the diagnoses and management of conditions in clients. The reported case shows that although, the basic infrastructure was limited, ultrasound scanning and Long Acting Reversible Contraception (LARC) trained midwives can ensure the provision of safe IUCD removal services in rural areas.

Leadership, governance and management for improving district capacity and performance: the case of USAID transform: primary health care.

BACKGROUND: Primary health care (PHC) in Ethiopia serves as the main entry point for preventive, promotive and curative health services. The district health office is responsible for the planning, implementation and evaluation of all district health activities. In addition, district health offices manage service delivery facilities working on provision of PHC - primary hospitals, health centers and health posts. As the leader of the health care system tier, district health management must ensure direction, alignment and commitment within teams and organizations and make sure that achievements are consistent with the vision, values and strategy of the organization. USAID Transform: Primary Health Care provides diverse support to improve district health manager competencies including in-service trainings followed by planning and implementation of performance improvement projects and on-the-job mentoring and support. METHODS: This study was conducted to compare district level capacity and performances between leadership, management and governance (LMG) and non-LMG districts. Project outcome monitoring data that shows the performance of districts was collected from 284 districts from January to December 2019. The study was carried out using a comparative-cross sectional study design, which assessed and compared district health office level indicators. Districts were classified into two categories: LMG and non-LMG districts. The study compared data from 94 LMG and 190 non-LMG districts. Propensity score matching was used to control the effect of differences between LMG and non-LMG districts. RESULTS: Results of the independent samples t-test revealed that LMG districts scored better average performances of 61.8 ± 121.45 standard deviation (SD) compared to non-LMG districts 56.89 ± 110.39 SD, with t (282243) = - 3.407317 and p < 0.001, two-tailed. The difference of 4.9 percentage unit in the average performance indicated a statistically significant difference between the LMG and non-LMG districts. CONCLUSION: District level leadership development program contributes to improving district capacity, structure and management practices, and quality of care.

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.

Improved performance of district health systems through implementing health center clinical and administrative standards in the Amhara region of Ethiopia.

BACKGROUND: Standards represent benchmarks against which improvements can be measured. In 2016, the Federal Ministry of Health developed and endorsed a set of standards entitled the Ethiopian Health Center Reform Implementation Guidelines (EHCRIGs). This study aims to assess the effects of planned interventions on performance and quality of services in primary health care units (PHCUs). METHODS: A quasi-experimental pre-post study design was used to compare the performance of PHCUs against the ECHRIG standards before and after its implementation in 76 woredas of the Amhara region from July - December 2017. Pre and post-intervention validation measurements of performance improvement in 76 woredas were conducted. The data were entered and analyzed using Statistical Package for Social Sciences. RESULT: For this study, ten sessions of two-day trainings were conducted for 1306 staff. Additionally, on-site mentoring and coaching was conducted for a period of three months. The average EHCRIG standards met before and after intervention totaled 59 and 66%, respectively. The scores showed a positive correlation coefficient (r = 0.74) with statistical significant paired sample t-test with t = - 7.15, df = 75, P < 0.000. In addition, the mean scores among performance tiers were 74, 66 and 65% for high, medium and low performing woredas respectively. The One-way Analysis of Variance (ANOVA) showed a borderline significant difference between groups with (F = 2.4, P < 0.09). CONCLUSIONS: The implementation of the standards has garnered significant improvements in performance at the primary health care level. Therefore, continuing the initiated strengthening of health system performance against the standards and evaluation of the quality of primary health services is recommended.

Factors associated with prelacteal feeding practices in Debre Berhan district, North Shoa, Central Ethiopia: a cross-sectional, community-based study.

BACKGROUND: Prelacteal feeding is one of the major harmful newborn feeding practices and is top on the list of global public health concerns. The practice deprives newborns of valuable nutrients and protection of colostrum and exposes them to preventable morbidity and mortality. Studying the prevalence and factors influencing the prelacteal feeding practice of mothers will help program managers and implementers to properly address broad major public health problems. Therefore, this study aims to investigate the prevalence of prelacteal feeding practices and its associated factors among mother-infant dyads in the Debre Berhan district of North Shoa administrative zone, central Ethiopia. METHODS: A community-based cross-sectional study design was conducted from January through to April 2014 among 634 mother-infant dyads. The data were entered into EPI Info version 3.5.1. (CDC, Atlanta, Georgia). All statistical analysis was conducted using Statistical Package for Social Sciences (SPSS) research IBM version 20.0. The prevalence of prelacteal feeding was determined using the 'recall since birth' method. Multi-variable logistic regression analysis was employed to control confounders in determining the association between prelacteal feeding practices and selected independent variables. Adjusted Odds Ratio (AOR), with 95% Confidence Interval (CI) and P < 0.05 was used to claim statistical significance. RESULTS: The prevalence of prelacteal feeding practice was 14.2% (95% CI: 11.00-17.00%). Slightly greater than half, 48 (53.3%) of prelacteal fed newborns were given butter. Home delivery was a major risk factor for practicing prelacteal feeding. Mothers who delivered their indexed infant at home practiced prelacteal feeding over four folds more than mothers who delivered in a health institution (Adjusted Odds Ratio (AOR) 4.70; 95% CI: 2.56-8.60, p-value = 0.001). Mothers who did not initiate breastfeeding within an hour were six times more likely to practice prelacteal feeding (AOR 5.58; 3.21-9.46, p-value = 0.001). Similarly, with regards to the occupation of mothers, farmers practiced prelacteal feedings (AOR 4.33; 95% CI: 1.73-10.81, p-value = 0.002) up to four folds more than their counterpart housewives. Mothers who can read and write are 54% less likely to practice prelacteal feeding than their counterpart, illiterate mothers, with (AOR 0.46; 95% CI: 0.22-0.98, p-value = 0.044). CONCLUSIONS: In the Debre Berhan town of North Shoa administrative zone, central Ethiopia, almost one-sixth of mothers practiced prelacteal feeding. Therefore, improving access to information about appropriate newborn feeding practices, encouraging mothers to deliver their babies in health institutions and inspiring them to initiate breastfeeding within an hour of birth is recommended.

Factors contributing to motivation of volunteer community health workers in Ethiopia: the case of four woredas (districts) in Oromia and Tigray regions.

BACKGROUND: The use of community health workers (CHWs) has been considered as one of the strategies to address the growing shortage of health workers, predominantly in low-income countries. They are playing a pivotal role in lessening health disparities through improving health outcomes for underserved populations. Yet, little is known about what factors motivate and drive them to continue working as CHWs. In this study, we aimed to examine factors contributing to the motivation of volunteer CHWs (vCHWs) in Ethiopia currently known as one-to-five network leaders (1to5NLs) and explore variations between attributes of social and work-related determinants. METHOD: We conducted a cross-sectional study in four selected woredas (the second lowest administrative structure in Ethiopia, and similar to a district) of Oromia and Tigray regions and interviewed 786 1to5NLs. The effects of each motivational factor were explored using percentage of respondents who agreed and strongly agreed to each of them and Mann-Whitney U test. RESULTS: Individual, community, and health system factors contributed to the motivation of 1to5NLs in this study. Intrinsic desire to have a good status in the community as a result of their volunteer service (81.86%) followed by a commitment to serve the community (81.61%) and to gain satisfaction by accomplishing something worthwhile to the community (81.61%) were some of the factors motivating 1to5NLs in our study. Despite these motivational items, factors such as lack of career development (51.47%), unclear health development army guideline (59.26%), limited supervision and support (62.32%), and lack of recognition and appreciation of accomplishments (63.22%) were the factors negatively affecting motivation of 1to5NLs. Lack of career development, limited supervision and support, and lack of recognition and appreciation of accomplishments were significantly varied between attributes of educational level, marital status, service year as 1to5NLs, and previous volunteer engagement (at P < 0.05). CONCLUSION: Findings of our study indicated that non-financial incentives such as the creation of career development models is the key to motivating and retaining CHWs where they are not receiving stipends. Sustainability of CHW program should consider exploring enhanced innovations to strengthen supportive supervision, development of better mechanisms to publicize the role of CHWs, and improvement of recognition and appreciation schemes for CHWs' efforts and accomplishments.