Spatial analysis of modern contraceptive use among women who need it in Ethiopia: Using geo-referenced data from performance monitoring for action.

INTRODUCTION: The challenge of achieving maternal and neonatal health-related goals in developing countries is significantly impacted by high fertility rates, which are partly attributed to limited access to family planning and access to the healthcare systems. The most widely used indicator to monitor family planning coverage is the proportion of women in reproductive age using contraception (CPR). However, this metric does not accurately reflect the true family planning coverage, as it fails to account for the diverse needs of women in reproductive age. Not all women in this category require contraception, including those who are pregnant, wish to become pregnant, sexually inactive, or infertile. To effectively address the contraceptive needs of those who require it, this study aims to estimate family planning coverage among this specific group. Further, we aimed to explore the geographical variation and factors influencing contraceptive uptake of contraceptive use among those who need. METHOD: We used data from the Performance Monitoring for Action Ethiopia (PMA Ethiopia) survey of women of reproductive age and the service delivery point (SDP) survey conducted in 2019. A total of 4,390 women who need contraception were considered as the analytical sample. To account for the study design, sampling weights were considered to compute the coverage of modern contraceptive use disaggregated by socio-demographic factors. Bayesian geostatistical modeling was employed to identify potential factors associated with the uptake of modern contraception and produce spatial prediction to unsampled locations. RESULT: The overall weighted prevalence of modern contraception use among women who need it was 44.2% (with 95% CI: 42.4%-45.9%). Across regions of Ethiopia, contraceptive use coverage varies from nearly 0% in Somali region to 52.3% in Addis Ababa. The average nearest distance from a woman's home to the nearest SDP was high in the Afar and Somali regions. The spatial mapping shows that contraceptive coverage was lower in the eastern part of the country. At zonal administrative level, relatively high (above 55%) proportion of modern contraception use coverage were observed in Adama Liyu Zone, Ilu Ababor, Misrak Shewa, and Kefa zone and the coverage were null in majority of Afar and Somali region zones. Among modern contraceptive users, use of the injectable dominated the method-mix. The modeling result reveals that, living closer to a SDP, having discussions about family planning with the partner, following a Christian religion, no pregnancy intention, being ever pregnant and being young increases the likelihood of using modern contraceptive methods. CONCLUSION: Areas with low contraceptive coverage and lower access to contraception because of distance should be prioritized by the government and other supporting agencies. Women who discussed family planning with their partner were more likely to use modern contraceptives unlike those without such discussion. Thus, to improve the coverage of contraceptive use, it is very important to encourage/advocate women to have discussions with their partner and establish movable health systems for the nomadic community.

Magnitude and determinants of early initiation and exclusive breastfeeding at six weeks postpartum: evidence from the PMA Ethiopia longitudinal survey.

BACKGROUND: Early initiation and exclusive breastfeeding are crucial in preventing child morbidity and mortality. Despite the importance of these practices, rates of timely initiation of breastfeeding and exclusive breastfeeding remain suboptimal in many sub-Saharan countries, including Ethiopia. This paper aimed to estimate the prevalence and identify determinants of breastfeeding initiation within the first hour after birth and exclusive breastfeeding in Ethiopia. METHODS: Data from the Performance Monitoring for Action Ethiopia project, a national survey conducted from August 2019 to September 2020, were used. The analytical sample comprises 2564 postpartum women and their children; data reported at baseline during enrollment and six weeks postpartum were used in this analysis. A multi-level binary logistic regression model was employed to identify determinant factors linked with initiation breastfeeding and exclusive breastfeeding. RESULTS: Of the 2564 mothers, 77.8% of infants breastfed within the first hour of birth and 68.4% of women practiced exclusive breastfeeding at six weeks postpartum with significant variation across regions. In the multivariate analysis, mothers who had cesarean delivery were less likely to initiate early breastfeeding as compared to mothers with vaginal delivery (AOR 0.27; 95% CI 0.17, 0.41). The odds of early initiation of breastfeeding were higher for mothers whose baby cried immediately after birth (AOR 3.31; 95% CI 1.95, 5.62) and who had skilled assisted delivery (AOR 2.13; 95% CI 1.01, 4.48). Other factors that were significantly associated with early initiation of breastfeeding were obstetric complication(s), parity, immediate mother-to-baby skin-to-skin contact, immediate postnatal care and the region. Similarly, mothers whose babies had a good neonatal birth status (AOR 1.81; 95% CI 1.09, 2.99) were more likely to exclusively breastfeed their child at six weeks postpartum. CONCLUSIONS: Early initiation of breastfeeding and exclusive breastfeeding is sub-optimal in Ethiopia. Nutrition programmers should consider regional variations in designing intervention programs to enhance breastfeeding practices. Healthcare providers should give special attention to women at risk such as those giving birth through cesarean section and having obstetric complications during delivery.

Contraceptive Intentions and Use throughout the Extended Postpartum Period: A Panel Study in Ethiopia.

The postpartum period is an ideal time for women to access contraception, but the prevalence of postpartum contraceptive use remains low in sub-Saharan Africa. To better understand the gap between women's desires to space or limit births and their contraceptive behaviors, intention to use contraception has been proposed as a person-centered measure of contraceptive demand. Using data from a panel study of Ethiopian women aged 15-49 who were interviewed at six weeks, six months, and one year postpartum, we examined the dynamics of contraceptive intention in the first year postpartum and its relationship with contraceptive use. Contraceptive intention fluctuated considerably in the year after childbirth. At six weeks, 60.9 percent of women intended to use a contraceptive method in the next year; 23.2% did not. By one year, less than half (43.5 percent) were using a method, and those who had no intention to use doubled (44.5 percent). Women who developed or sustained their intention to use a method in the postpartum period were more likely to adopt a method by one year than those who did not, showing that contraceptive intention is a strong predictor of use and has the potential to inform person-centered reproductive health programming in the extended postpartum period.

Self-reported abortion experiences in Ethiopia and Uganda, new evidence from cross-sectional community-based surveys.

Unsafe abortion is a major contributor to maternal morbidity and mortality. To gain insight into the ways in which abortion restrictions and stigma may shape reproductive health outcomes, we present self-reported data on abortions in Ethiopia and Uganda and compare these findings across the two varying legal contexts. W investigate differences in sociodemographic characteristics by whether or not a woman self-reported an abortion, and we describe the characteristics of women's most recent self-reported abortion. In Ethiopia only, we classified abortions as being either safe, less safe, or least safe. Finally, we estimate minimum one-year induced abortion incidence rates using the Network Scale-Up Method (NSUM). We find that women who self-reported abortions were more commonly older, formerly married, or had any children compared to women who did not report an abortion. While three-quarters of women in both settings accessed their abortion in a health facility, women in Ethiopia more commonly used public facilities as compared to in Uganda (23.0% vs 12.6%). In Ethiopia, 62.4% of self-reported abortions were classified as safe, and treated complications were more commonly reported among least and less safe abortions compared to safe abortions (21.4% and 23.1% vs. 12.4%, respectively). Self-reported postabortion complications were more common in Uganda (37.2% vs 16.0%). The NSUM estimate for the minimum one-year abortion incidence rate was 4.7 per 1000 in Ethiopia (95% CI 3.9-5.6) and 19.4 per 1000 in Uganda (95% C 16.2-22.8). The frequency of abortions and low levels of contraception use at the time women became pregnant suggest a need for increased investments in family planning services in both settings. Further, it is likely that the broadly accessible nature of abortion in Ethiopia has made abortions safer and less likely to result in complications in Ethiopia as compared to Uganda.

Exploring Multiple Measures of Pregnancy Preferences and Their Relationship with Postpartum Contraceptive Uptake Using Longitudinal Data from PMA Ethiopia.

There are significant gaps in our understanding of how the experience of an unintended pregnancy affects subsequent contraceptive behavior. Our objective was to explore how three measures of pregnancy preferences-measuring timing-based intentions, emotional orientation, and planning status-were related to the uptake of postpartum family planning within one year after birth. Additionally, we tested whether the relationship between each measure and postpartum family planning uptake differs by parity, a key determinant of fertility preference. Adjusted hazards regression results show that the timing-based measure, specifically having a mistimed pregnancy, and the emotional response measure, specifically being unhappy, were associated with contraceptive uptake in the extended postpartum period, while those related to pregnancy planning, as measured by an adapted London Measure of Unplanned Pregnancy, were not. This effect differed by parity; high parity women were consistently the least likely to use contraception in the postpartum period, but the effect of experiencing an unwanted pregnancy or having a mixed reaction to a pregnancy was significantly stronger among high parity compared to low parity women. Greater attention to the entirety of women's responses to unanticipated pregnancies is needed to fully understand the influence of unintended pregnancy on health behaviors and outcomes for women and their children.

The more, the better: influence of family planning discussions during the maternal, newborn and child health continuum of care on postpartum contraceptive uptake and method type among young women in Ethiopia.

Background: This study examines the association between family planning (FP) discussions with health professionals during contact points on the maternal, newborn and child health continuum of care and timing of modern contraceptive uptake and method type in the one-year following childbirth in six regions of Ethiopia among adolescent girls and young women (AGYW). Methods: This paper uses panel data of women aged 15-24 who were interviewed during pregnancy and the postpartum period between 2019-2021 as part of the PMA Ethiopia survey (n=652).  Results: Despite the majority of pregnant and postpartum AGYW attending antenatal care (ANC), giving birth in a health facility, and attending vaccination visits, one-third or less of those who received the service reported discussion of FP at any of these visits. When considering the cumulative effect of discussions of FP at ANC, pre-discharge after childbirth, postnatal care and vaccination visits, we found that discussion of FP at a greater number of visits resulted in increased uptake of modern contraception by one-year postpartum. A greater number of FP discussions was associated with higher long-acting reversible contraceptive use relative to non-use and relative to short-acting method use. Conclusions: Despite high attendance, there are missed opportunities to discuss FP when AGYW access care.

Predicting nutritional status during pregnancy by women's empowerment in West Shewa Zone, Ethiopia.

Background: Considerable proportions of pregnant women are affected by poor nutrition outcomes in Ethiopia. Women's empowerment, on the other hand, is highly recognized as a means to achieve better maternal nutrition outcomes. However, the role of pregnant women's empowerment in nutritional status during pregnancy has not been empirically examined in Ethiopia. This study aimed to address this gap. Objective: To assess the association of individual and composite women's empowerment dimensions with pregnant women's nutrition outcomes in West Shewa Zone, Ethiopia. Methods: A health facility-based cross-sectional study was performed on 1,453 pregnant women living in West Shewa Zone, Ethiopia, in 2021. Exploratory and confirmatory factor analyses were conducted on half of the samples to identify and validate dimensions of pregnant women's empowerment. The associations between pregnant women's empowerment dimensions and anemia status and mid upper arm circumference levels were examined by logistic regressions. Results: Composite pregnant women's empowerment was positively associated with both anemia status and mid-upper-arm circumference level. The odds of not being anemic were higher among pregnant women empowered in economic [adjusted odds ratio (AOR) = 1.7, 95% confidence interval (CI): 1.26, 2.22] and assertiveness (AOR = 1.9, 95% CI: 1.46, 2.38) dimensions than those not empowered in these dimensions. Empowered pregnant women in household decision-making (AOR = 1.6, 95% CI: 1.19, 2.22) and psychological (AOR = 1.4, 95% CI: 1.04, 1.85) dimensions had higher odds of having normal mid-upper-arm circumference measures than those not empowered in the respective dimensions. Communication and time dimensions were not significantly associated with any of the nutrition outcomes. Conclusions: This study suggests that empowered pregnant women are nutritionally better off than their less empowered counterparts. This is also important in child health outcomes. Policies and programs that aim to improve maternal and child health in the study area need to consider interventions that promote the decision-making power, economic, psychological, and assertiveness dimensions of pregnant women.

Impact of the global gag rule on women's contraceptive use and reproductive health outcomes in Ethiopia: a pre-post and difference-in-difference analysis.

OBJECTIVE: To assess the impacts of the Protecting Life through Global Health Assistance policy (otherwise known as the expanded global gag rule (GGR)) on women's sexual and reproductive health (SRH) in Ethiopia. The GGR prohibits all non-US non-governmental organisations (NGOs) receiving US Government global health funding from providing, referring or advocating for abortion. DESIGN: Pre-post analysis and difference-in-difference analysis. SETTING: Six regions of Ethiopia (Tigray, Afar, Amhara, Oromiya, SNNPR and Addis Ababa). PARTICIPANTS: Panel of 4909 reproductive-age women recruited from the Performance Monitoring for Accountability 2018 survey, administered face-to-face surveys in 2018 and 2020. MEASURES: We assessed impacts of the GGR on contraceptive use, pregnancies, births and abortions. Due to the 2019 'Pompeo Expansion' and widespread application of the GGR, we use a pre-post analysis to investigate changes in women's reproductive outcomes. We then use a difference-in-differences design to measure the additional effect of NGOs refusal to comply with the policy and the resulting loss in funding; districts are classified as more exposed if organisations impacted by lost funding were providing services there and women are classified based on their district. RESULTS: At baseline, 27% (n=1365) of women were using a modern contraceptive (7% using long-acting reversible contraceptive methods (LARCs) and 20% using short-acting methods. The pre-post analysis revealed statistically significant declines from 2018 to 2020 in the use of LARCs (-0.9, 95% CI: -1.6 to -0.2) and short-acting methods (-1.0, 95% CI: -1.8 to -0.2). These changes were deviations from prior trends. In our difference-in-differences analysis, women exposed to non-compliant organisations experienced greater declines in LARC use (-1.5, 95% CI: -2.9 to -0.1) and short-acting method use (-1.7, 95% CI: -3.2 to -0.1) as compared with less-exposed women. CONCLUSIONS: The GGR resulted in a stagnation in the previous growth in contraceptive use in Ethiopia. Longer-term strategies are needed to ensure that SRH progress globally is protected from changes in US political administrations.

Evaluation of the London Measure of Unplanned Pregnancy (LMUP) among a nationally representative sample of pregnant and postpartum women Ethiopia.

Objectives: Rigorous measurement of pregnancy preferences is needed to address reproductive health needs. The London Measure of Unplanned Pregnancy (LMUP), developed in the UK, has been adapted for low-income countries. Psychometric properties of LMUP items remain uncertain in contexts with limited access to and use of health services. Study design: This cross-sectional study examines the six-item LMUP's psychometric properties among a nationally representative sample of 2855 pregnant and postpartum women in Ethiopia. Principal components analysis (PCA) and confirmatory factor analysis (CFA) estimated psychometric properties. Hypothesis testing examined associations between the LMUP and other measurement approaches of pregnancy preferences using descriptive statistics and linear regression. Results: The six-item LMUP had acceptable reliability (α = 0.77); two behavioral items (contraception, preconception care) were poorly correlated with the total scale. A four-item measure demonstrated higher reliability (α = 0.90). Construct validity via PCA and CFA indicated the four-item LMUP's unidimensionality and good model fit; all hypotheses related to the four-item LMUP and other measurement approaches were met. Conclusions: Measurement of women's pregnancy planning in Ethiopia may be improved through use of a four-item version of the LMUP scale. This measurement approach can inform family planning services to better align with women's reproductive goals. Implications: Improved pregnancy preference measures are needed to understand reproductive health needs. A four-item version of the LMUP is highly reliable in Ethiopia, offering a robust and concise metric for assessing women's orientations toward a current or recent pregnancy and tailoring care to support them in achieving their reproductive goals.

Postabortion and safe abortion care coverage, capacity, and caseloads during the global gag rule policy period in Ethiopia and Uganda.

BACKGROUND: Abortion-related complications contribute to preventable maternal mortality, accounting for 9.8% of maternal deaths globally, and 15.6% in sub-Saharan Africa. High-quality postabortion care (PAC) can mitigate the negative health outcomes associated with unsafe abortion. While the expanded Global Gag Rule policy did not prohibit the provision of PAC, other research has suggested that over-implementation of the policy has resulted in impacts on these services. The purpose of this study was to assess health facilities' capacity to provide PAC services in Uganda and PAC and safe abortion care (SAC) in Ethiopia during the time in which the policy was in effect. METHODS: We collected abortion care data between 2018 and 2020 from public health facilities in Ethiopia (N = 282) and Uganda (N = 223). We adapted a signal functions approach to create composite indicators of health facilities' capacity to provide basic and comprehensive PAC and SAC and present descriptive statistics documenting the state of service provision both before and after the GGR went into effect. We also investigate trends in caseloads over the time-period. RESULTS: In both countries, service coverage was high and improved over time, but facilities' capacity to provide basic PAC services was low in Uganda (17.8% in 2019) and Ethiopia (15.0% in 2020). The number of PAC cases increased by 15.5% over time in Uganda and decreased by 7% in Ethiopia. Basic SAC capacity increased substantially in Ethiopia from 66.7 to 82.8% overall, due in part to an increase in the provision of medication abortion, and the number of safe abortions increased in Ethiopia by 9.7%. CONCLUSIONS: The findings from this analysis suggest that public health systems in both Ethiopia and Uganda were able to maintain essential PAC/SAC services during the GGR period. In Ethiopia, there were improvements in the availability of safe abortion services and an overall improvement in the safety of abortion during this time-period. Despite loss of partnerships and potential disruptions in referral chains, lower-level facilities were able to expand their capacity to provide PAC services. However, PAC caseloads increased in Uganda which could indicate that, as hypothesized, abortion became more stigmatized, less accessible and less safe.

Understanding variation in person-centered maternity care: Results from a household survey of postpartum women in 6 regions of Ethiopia.

BACKGROUND: Effective communication, respect and dignity, and emotional support are critical for a positive childbirth experience that is responsive to the needs and preferences of women. OBJECTIVE: This study evaluated the performance of a person-centered maternity care scale in a large, representative household sample of postpartum women, and it describes differences in person-centered maternity care across individuals and communities in Ethiopia. STUDY DESIGN: The study used data from 2019 and 2020 from a representative sample of postpartum women in 6 regions of Ethiopia. It measured person-centered maternity care using a scale previously validated in other settings. To assess the scale validity in Ethiopia, we conducted cognitive interviews, measured internal consistency, and evaluated construct validity. Then, we fit univariable and multivariable linear regression models to test for differences in mean person-centered maternity care scores by individual and community characteristics. Lastly, multilevel modeling separated variance in person-centered maternity care scores within and between communities. RESULTS: Effective communication and support of women's autonomy scored lowest among person-centered maternity care domains. Of 1575 respondents, 704 (44.7%) were never asked their permission before examinations and most said that providers rarely (n=369; 23.4%) or never (n=633; 40.2%) explained why procedures were done. Person-centered maternity care was significantly higher for women with greater wealth, more formal education, and those aged >20 years. Variation in person-centered maternity care scores between individuals within the same community (τ2=58.3) was nearly 3 times greater than variation between communities (σ2=21.2). CONCLUSION: Ethiopian women reported widely varying maternity care experiences, with individuals residing within the same community reporting large differences in how they were treated by providers. Poor patient-provider communication and inadequate support of women's autonomy contributed most to poor person-centered maternity care.

What is the relationship between contraceptive services and knowledge of abortion availability and legality? Evidence from a national sample of women and facilities in Ethiopia.

In Ethiopia, abortions are legal for minors and for rape, incest, foetal impairment or maternal disability. Knowledge of abortion legality and availability is low, and little effort has been made to disseminate this information for fear of invoking anti-abortion sentiment; instead, systems rely on health providers as information gatekeepers. This study explores how exposure to and interaction with family planning service delivery environment, specifically (1) availability of contraceptive and facility-based abortion services within 5 km of one's residence and (2) contact with a health provider in the past 12 months, relate to women's knowledge of the legality of accessing abortion services and of where to access facility-based abortion services. We used data from a nationally representative sample of 8719 women in Ethiopia and a linked health facility survey of 799 health facilities. Our outcome of interest was a categorical variable indicating if a woman had (1) knowledge of at least one legal ground for abortion, (2) knowledge of where to access abortion services, (3) knowledge of both or (4) knowledge of neither. We conducted multilevel, multinomial logistic regressions, stratified by residence. Approximately 60% of women had no knowledge of either a legal ground for abortion or a place to access services. Women who visited a health provider or who were visited by a health worker in the past 12 months were significantly more likely to know about abortion legality and availability. There were no differences based on whether women lived within 5 km of a facility that offered contraception and abortion services. We find that health workers are likely valuable sources of information; however, progress to disseminate information may be slowed if it relies on uptake of services and limited outreach. Efforts to train providers on legality and availability are critical, as is additional research on knowledge dissemination pathways.

Pregnancy coercion, correlates, and associated modern contraceptive use within a nationally representative sample of Ethiopian women.

Partner-perpetrated pregnancy coercion inhibits women's reproductive autonomy. However, few studies have quantified pregnancy coercion and its effects on women's health within low- and middle-income countries. Among a national sample of Ethiopian women, this study aimed to: (1) assess the prevalence of past-year pregnancy coercion and explore regional differences; (2) identify correlates; (3) examine the relationship between pregnancy coercion and modern contraceptive use. Analyses utilise cross-sectional data from Performance Monitoring for Action (PMA)-Ethiopia, a nationally representative sample of females aged 15-49 conducted from October to November 2019. Past-year pregnancy coercion was assessed via five items and analysed dichotomously and categorically for severity. Among women in need of contraception, bivariate and multivariable logistic regression examined associations between variables of interest, per aim, accounting for sampling weights and clustering by enumeration area. Approximately 20% of Ethiopian women reported past-year pregnancy coercion (11.4% less severe; 8.6% more severe), ranging from 16% in Benishangul-Gumuz to 35% in Dire Dawa. Increasing parity was associated with decreased odds of pregnancy coercion. Among women in need of contraception, experience of pregnancy coercion was associated with a 32% decrease in odds of modern contraceptive use (aOR = 0.68; 95% CI: 0.53-0.89); when disaggregated by severity, odds decreased for most severe pregnancy coercion (aOR = 0.59; 95% CI = 0.41-0.83). Results indicate that partner-perpetrated pregnancy coercion is prevalent across diverse regions of Ethiopia, and most severe forms could interrupt recent gains in contraceptive coverage and progress to sexual and reproductive health and rights. Providers must be aware of potential contraceptive interference and address coercive influences during contraceptive counselling.

Do users of long-acting reversible contraceptives receive the same counseling content as other modern method users? A cross-sectional, multi-country analysis of women's experiences with the Method Information Index in six sub-Saharan African countries.

Objective: There has been a growing focus on informed choice in contraceptive research. Because removal of long-acting reversible contraception (LARC), including implants and IUDs, requires a trained provider, ensuring informed choice in the adoption of these methods is imperative. We sought to understand whether information received during contraceptive counseling differed among women using LARC and those using other modern methods of contraception. Study Design: We used cross-sectional data from Burkina Faso, Côte d'Ivoire, the Democratic Republic of Congo (DRC), Kenya, Nigeria, and Uganda collected in 2019-2020 by the Performance Monitoring for Action project. We included 7969 reproductive-aged women who reported use of modern contraception. Our outcome of interest, information received during contraceptive counseling, was measured using a binary indicator of whether respondents answered "yes" to all 4 questions that make up the Method Information Index Plus (MII+). We used modified Poisson models to estimate the prevalence ratio between method type (LARC vs. other modern methods) and the MII+, controlling for individual- and facility-level covariates. Results: Reported receipt of the full MII+ during contraceptive counseling ranged from 21% in the DRC to 51% in Kenya. In all countries, a higher proportion of LARC users received the MII+ compared to other modern method users. A greater proportion of LARC users answered "yes" to all questions that make up the MII+ at the time of counseling compared to other modern method users in DRC, Kenya, Nigeria, and Uganda. There was no significant difference in the prevalence of reporting the full MII+ between users of LARC and other modern methods in Burkina Faso (Adjusted prevalence ratio (aPR): 1.16; 95% confidence interval (CI): 0.91, 1.48) and Côte d'Ivoire (aPR: 1.13; 95% CI: 0.87, 1.45). Conclusion: Information received during contraceptive counseling was limited for all modern contraceptive users. LARC users had significantly higher prevalence of receiving the MII+ compared to other modern method users in the DRC, Kenya, and Uganda. Family planning programs should ensure that all women receive complete, unbiased contraceptive counseling. Implications: Across 6 sub-Saharan African countries, a substantial proportion reproductive-aged women using contraception did not report receiving comprehensive counseling when they received their method. Women using long-acting reversible contraception received more information compared to women using other modern methods in the DRC, Kenya, Nigeria, and Uganda after controlling for individual- and facility-level factors.

The impact of partner autonomy constraints on women's health-seeking across the maternal and newborn continuum of care.

Background: Gendered health inequities impede women's reproductive autonomy over the life course. Pregnancy is a critical time point for assessing inequities and partners are integral actors in the achievement or impediment of women's and children's health during this time. Methods: Among a nationally representative cohort of Ethiopian women 5-9 weeks postpartum with data collected from October 2019-September 2020, this study aimed to 1) understand the prevalence and interplay of partner-related autonomy constraints (intimate partner violence (IPV), reproductive coercion (RC), lack of encouragement from seeking antenatal care (ANC), and lack of encouragement from seeking postnatal care (PNC), and 2) examine the impact of autonomy constraints on the maternal and newborn health (MNH) continuum of care. Findings: Sixty percent of women experienced a partner-related autonomy constraint prior to or during pregnancy. Approximately 20% of women were not encouraged to seek antenatal care and postpartum care, respectively, whereas fewer women experienced IPV during pregnancy (12.3%) and RC (11.0%). Less than one in five women completed the MNH continuum of care. Lack of encouragement of ANC and PNC were associated with decreased care-seeking at every point across the MNH continuum of care. Lack of encouragement of ANC (aOR = 0.45; p = 0.05) and of PNC (aOR = 0.16; p < 0.001) were associated with reductions in completing the continuum. Interpretation: Partner engagement, interventions, and messaging are critical to enhance MNH care-seeking behaviors. Funding: This work was supported, in whole, by the Bill & Melinda Gates Foundation [INV 009466]. Under the grant conditions of the Foundation, a Creative Commons Attribution 4.0 Generic License has already been assigned to the Author Accepted Manuscript version that might arise from this submission.

Availability of postabortion care services in Ethiopia: Estimates from a 2020 national sample of public facilities.

Objectives: Unsafe abortion is a leading cause of global maternal mortality and morbidity. This study sought to estimate availability of essential postabortion care (PAC) services among publicly managed health facilities in Ethiopia. Study design: Data from public hospitals and health centers in Ethiopia were collected in 2020. Among facilities offering labor and delivery, we assessed the proportion that: (1) offered PAC, (2) were equipped for each PAC signal function, and (3) were equipped for all PAC signal functions falling within their scope of care by facility type. Analysis: Our primary outcome was PAC service provision status. Descriptive statistics summarized the proportion of hospitals and health centers, respectively, categorized as each PAC status and with necessary equipment for individual signal functions. Per Federal Ministry of Health (FMOH) guidelines, hospitals are expected to provide comprehensive PAC, while health centers are expected to provide basic PAC. Results: Altogether, 69.1% (n = 94) of hospitals were equipped to provide comprehensive PAC, and 65.2% (n = 131) of health centers were equipped for basic PAC. Least available signal functions included obstetric surgery among hospitals (83.8%; n = 114) and uterine evacuation among health centers (84.6%; n = 170). Conclusion: Meaningful progress has been made toward achieving the Ethiopian FMOH's goal of universal PAC service availability at hospitals and health centers by 2020. Despite this, sizable gaps remain and may endanger maternal health in Ethiopia, underscoring a need for continued prioritization of PAC services. Implications: Ethiopia's commitment to PAC has fostered a service landscape that is stronger than many other low-resource settings; however, notable shortcomings are present. Further research is needed to understand the potential role of clinical training and supply-side interventions.

Pregnancy coercion and partner knowledge of contraceptive use among Ethiopian women.

Objective: To examine the relationship between pregnancy coercion and partner knowledge of contraceptive use. Study design: Cross-sectional Performance Monitoring for Action-Ethiopia data were collected in October-November 2019 from a nationally representative sample of women ages 15 to 49. The analytical sample (n = 2,469) included partnered women using contraception in the past year. We used multinomial logistic regression to examine associations between past-year pregnancy coercion (none, less severe, more severe) and partner knowledge/couple discussion of contraceptive use (overt use with couple discussion before method initiation (reference group), overt use with discussion after method initiation, and covert use of contraception). Results: Most women reported their partner knew they were using contraception and had discussed use prior to method initiation (1,837/2,469, 75%); 16% used overtly and discussed use after method initiation, and 7% used contraception covertly. The proportion of covert users increased with pregnancy coercion severity (4%none, 14%less severe, 31%more severe), as did the proportion of overt users who delayed couple contraceptive discussions, (14%none, 23%less severe, 26% more severe); however, overt use with couple discussion before method initiation decreased with pregnancy coercion severity (79%none, 60%less severe, 40%more severe). The risk of covert use among women experiencing less severe pregnancy coercion was four times greater than women who experienced no pregnancy coercion (adjusted relative risk ratio, (aRRR) = 3.95, 95% confidence interval (CI) 2.20-7.09) and ten times greater for women who experienced the most severe pregnancy coercion (aRRR = 10.42, 95% CI 6.14-17.71). The risk of overt use with delayed couple discussion also increased two-fold among women who experienced pregnancy coercion compared to those who did not (less severe aRRR = 2.05, 95% CI 1.39-2.99; more severe aRRR = 2.89, 95% CI 1.76-4.73). Conclusion: When experiencing pregnancy coercion, women may avoid or delay contraceptive conversations with their partners. Increased pregnancy coercion severity has the greatest association with covert use and couple contraceptive discussions. Implications: The presence and timing of couple discussions about contraception are critical for ensuring safety for women experiencing pregnancy coercion. Screening for pregnancy coercion must be included within contraceptive counseling so that women can choose methods that maximize their reproductive autonomy.

Impact of the Early Stages of the COVID-19 Pandemic on Coverage of Reproductive, Maternal, and Newborn Health Interventions in Ethiopia: A Natural Experiment.

Background: The COVID-19 pandemic and response have the potential to disrupt access and use of reproductive, maternal, and newborn health (RMNH) services. Numerous initiatives aim to gauge the indirect impact of COVID-19 on RMNH. Methods: We assessed the impact of COVID-19 on RMNH coverage in the early stages of the pandemic using panel survey data from PMA-Ethiopia. Enrolled pregnant women were surveyed 6-weeks post-birth. We compared the odds of service receipt, coverage of RMNCH service indicators, and health outcomes within the cohort of women who gave birth prior to the pandemic and the COVID-19 affected cohort. We calculated impacts nationally and by urbanicity. Results: This dataset shows little disruption of RMNH services in Ethiopia in the initial months of the pandemic. There were no significant reductions in women seeking health services or the content of services they received for either preventative or curative interventions. In rural areas, a greater proportion of women in the COVID-19 affected cohort sought care for peripartum complications, ANC, PNC, and care for sick newborns. Significant reductions in coverage of BCG vaccination and chlorohexidine use in urban areas were observed in the COVID-19 affected cohort. An increased proportion of women in Addis Ababa reported postpartum family planning in the COVID-19 affected cohort. Despite the lack of evidence of reduced health services, the data suggest increased stillbirths in the COVID-19 affected cohort. Discussion: The government of Ethiopia's response to control the COVID-19 pandemic and ensure continuity of essential health services appears to have successfully averted most negative impacts on maternal and neonatal care. This analysis cannot address the later effects of the pandemic and may not capture more acute or geographically isolated reductions in coverage. Continued efforts are needed to ensure that essential health services are maintained and even strengthened to prevent indirect loss of life.