What Underlies State Government Performance in Scaling Family Planning Programming? A Study of The Challenge Initiative State Partnerships in Nigeria.

INTRODUCTION: Relatively few studies rigorously examine the factors associated with health systems strengthening and scaling of interventions at subnational government levels. We aim to examine how The Challenge Initiative (TCI) coaches subnational (state government) actors to scale proven family planning and adolescent and youth sexual and reproductive health approaches rapidly and sustainably through public health systems to respond to unmet need among the urban poor. METHODS: This mixed-methods comparative case study draws on 32 semistructured interviews with subnational government leaders and managers, nongovernmental organization leaders, and TCI Nigeria staff, triangulated with project records and government health management information system (HMIS) data. Adapting the Consolidated Framework for Implementation Research (CFIR), we contrast experience across 2 higher-performing states and 1 lower-performing state (identified through HMIS data and selected health systems strengthening criteria from 13 states) to identify modifiable factors linked with successful adoption and implementation of interventions and note lessons for supporting scale-up. RESULTS: Informants reported that several TCI strategies overlapping with CFIR were critical to states' successful adoption and sustainment of interventions, most prominently external champions' contributions and strengthened state planning and coordination, especially in higher-performing states. Government stakeholders institutionalized new interventions through their annual operational plans. Higher-performing states incorporated mutually reinforcing interventions (including service delivery, demand generation, and advocacy). Although informants generally expressed confidence that newly introduced service delivery interventions would be sustained beyond donor support, they had concerns about government financing of demand-side social and behavior change work. CONCLUSION: As political and managerial factors, even more than technical factors, were most linked with successful adoption and scale-up, these processes and systems should be assessed and prioritized from the start. Government leaders, TCI coaches, and other stakeholders can use these findings to shape similar initiatives to sustainably scale social service interventions.

How The Challenge Initiative Adapted and Used Pause and Reflect Responsive Feedback Sessions for Adaptive Management in Nigeria.

BACKGROUND: The Challenge Initiative (TCI) supports state governments to effectively and sustainably scale up family planning and reproductive health (FP/RH) programming in Nigeria. Given the limited evidence on successful scale-up of health interventions, TCI has established responsive feedback (RF) approaches to regularly review and reflect upon its strategies to quickly adapt and document lessons for scaling FP/RH interventions. One of the RF components adopted was pause and reflect (P&R) exercises to facilitate adaptive management. METHODS: TCI conducted quarterly P&R exercises to identify what works, adapt strategies where needed, and document lessons learned. These exercises were typically conducted as focus group discussions where staff members deliberated on a topic, strategy, or action and discussed how best to refine, diffuse, or discard it. About 10-15 staff participated in each session, including country office technical advisors, state program managers, and technical leads. RESULTS: TCI has conducted 4 P&R exercises to date. The first P&R focused on identifying effective strategies for scaling up FP/RH interventions and led to the recognition of TCI's coaching strategy and FP in-reaches as evidence-based approaches. The second P&R focused on how to improve TCI's Reflection and Action to Improve Self-reliance and Effectiveness tool to effectively measure governments' capacity to implement FP/RH interventions. The third P&R on graduation activities of TCI's first phase states revealed best practices for planning graduation activities for its second phase states. The fourth P&R on TCI's coaching strategy showed that geographies require a more structured coaching plan to effectively manage their coaching interventions. Implementation of identified actions from the P&R exercises contributed to noticeable improvements in programming. CONCLUSION: The P&R exercise has contributed to improvements in adaptive management in TCI programming in Nigeria and is recommended for use by implementing partners, government officials, and other community stakeholders as a useful RF tool.

Professionalism, stigma, and willingness to provide patient-centered safe abortion counseling and care: a mixed methods study of Ethiopian midwives.

BACKGROUND: Midwives are a large proportion of Ethiopia's health care workforce, and their attitudes and practices shape the quality of reproductive health care, including safe abortion care (SAC) services. This study examines how midwives' conceptions of their professional roles and views on women who have abortions relate to their willingness to provide respectful SAC. METHODS: This study uses a cross-sectional, mixed methods design to conduct a regionally representative survey of midwives in Ethiopia's five largest regions (Oromia; Amhara; Southern Nations, Nationalities, and Peoples [SNNP]; Tigray; and Addis Ababa) with a multistage, cluster sampling design (n = 944). The study reports survey-weighted population estimates and the results of multivariate logistic regression analyzing factors associated with midwives' willingness to provide SAC. Survey data were triangulated with results from seven focus group discussions (FGDs) held with midwives in the five study regions. Deductive and inductive codes were used to thematically analyze these data. RESULTS: The study surveyed 960 respondents. An estimated half of midwives believed that providing SAC was a professional duty. Slightly more than half were willing to provide SAC. A belief in right of refusal was common: two-thirds of respondents said that midwives should be able to refuse SAC provision on moral or religious grounds. Modifiable factors positively associated with willingness to provide SAC were SAC training (AOR 4.02; 95% CI 2.60, 6.20), agreeing that SAC refusal risked women's lives (AOR 1.69; 95% CI 1.20, 2.37), and viewing SAC provision as a professional duty (AOR 1.72; 95% CI 1.23, 2.39). In line with survey findings, a substantial number of FGD participants stated they had the right to refuse SAC. Responses to client scenarios revealed "directive counseling" to be common: many midwives indicated that they would actively attempt to persuade clients to act as they (the midwives) thought was best, rather than support clients in making their own decisions. CONCLUSION: Findings suggest a need for new guidelines to clarify procedures surrounding conscientious objection and refusal to provide SAC, as well as initiatives to equip midwives to provide rights-based, patient-centered counseling and avoid directive counseling.

When health care workers refuse to provide safe abortion care (SAC) for religious, moral, or personal reasons, they jeopardize their clients' health and violate the right to care. Scholars believe that health care workers' professional commitments to patient care and to their profession's goals can help them prioritize patient care over their personal biases. The Ethiopian government has assigned midwives a central responsibility to provide SAC, but there is no comprehensive understanding of Ethiopian midwives' willingness to provide SAC and allied rationales, or the relationships between their sense of professional duty and willingness to provide.To answer these questions, a survey and focus groups with midwives in Ethiopia's five most populated regions were conducted. Almost half of midwives were unwilling to provide SAC, and half disbelieved that it was midwives' duty to do so. Most believed that midwives should be able to refuse to provide SAC based on religious or moral objections. Midwives were motivated to provide care by a belief that clients would die without care and by a sense of professional duty. When asked about how they would treat women requesting abortion care and contraceptives, many midwives said that they would encourage the woman to do what the midwife him- or herself thought best, rather than support her in making her own decision.These regionally representative findings suggest the need for new provider guidelines to clarify practices surrounding conscientious objection and refusal to provide safe abortion care and for programs to better train midwives to provide respectful counseling.

Agenda setting and socially contentious policies: Ethiopia's 2005 reform of its law on abortion.

BACKGROUND: In 2005, Ethiopia took a bold step in reforming its abortion law as part of the overhaul of its Penal Code. Unsafe abortion is one of the three leading causes of maternal mortality in low-income countries; however, few countries have liberalized their laws to permit safer, legal abortion. METHODS: This retrospective case study describes the actors and processes involved in Ethiopia's reform and assesses the applicability of theories of agenda setting focused on internal versus external explanations. It draws on 54 interviews conducted in 2007 and 2012 with informants from civil society organizations, health professionals, government, international nongovernmental organizations and donors, and others familiar with the reproductive health policy context in Ethiopia as well as on government data, national policies, and media reports. The analytic methodology is within-case analysis through process tracing: using causal process observations (pieces of data that provide information about context, process, or mechanism and can contribute to causal inference) and careful description and sequencing of factors in order to describe a novel political phenomenon and evaluate potential explanatory hypotheses. RESULTS: The analysis of key actors and policy processes indicates that the ruling party and its receptiveness to reform, the energy of civil society actors, the "open windows" offered by the vehicle of the Penal Code reform, and the momentum of reforms to improve women's status, all facilitated liberalization of law on abortion. Results suggest that agenda setting theories focusing on national actors-rather than external causes-better explain the Ethiopian case. In addition, the stronger role for government across areas of policy work (policy specification and politics, mobilization for enactment and for implementation), and the collaborative civil society and government policy relationships working toward implementation are largely internal, unlike those predicted by theories focusing on external forces behind policy adoption. CONCLUSIONS: Ethiopia's policymaking process can inform policy reform efforts related to abortion in other sub-Saharan Africa settings.

Globally, deaths of women due to unsafe abortion remain high. However, few countries have changed their laws to allow safer, legal abortion. In 2005, Ethiopia reformed its law to permit women to obtain an abortion for a significantly greater number of reasons, and this reform has resulted in a real expansion of women's access to services.This retrospective case study uses information from interviews with 54 people involved in Ethiopia's reform and from government and research documents to see whether explanations of the reform that focus on the roles of national actors versus on the roles of external actors and influences better explain how Ethiopia's reform took place.This study finds that national actors and processes were most central to Ethiopia's reform. In particular, a ruling party open to reform, the work of the women's movement and of reproductive health nongovernmental organizations, the ability to take advantage of political events, and the collaborative relationship between government and nongovernmental organizations all supported reform. At the time, many major external actors were either against the reform (the U.S. government) or stayed neutral.Findings can help those seeking to understand or plan policy reform efforts in other sub-Saharan Africa countries.

Perceptions of cervical cancer care among Ethiopian women and their providers: a qualitative study.

BACKGROUND: Cervical cancer is the second most commonly diagnosed cancer among Ethiopian women, killing an estimated 4700 women each year. As the government rolls out the country's first national cancer control strategy, information on patient and provider experiences in receiving and providing cervical cancer screening, diagnosis, and treatment is critical. METHODS: This qualitative study aimed to assess the availability of cervical cancer care; explore care barriers and sources of delay; and describe women's and providers' perceptions and experiences of care. We analyzed data from 45 informants collected at 16 health centers, district hospitals and referral hospitals in East Gojjam Zone and a support center in Addis Ababa. Thirty providers and ten women receiving care were interviewed, and five women in treatment or post-treatment participated in a focus group discussion. Deductive and inductive codes were used to thematically analyze data. RESULTS: Providers lacked equipment and space to screen and treat patients and only 16% had received in-service cervical cancer training. Consequently, few facilities provided screening or preventative treatment. Patients reported low perceptions of risk, high stigma, a lack of knowledge about cervical cancer, and delayed care initiation. All but one patient sought care only when she became symptomatic, and, pre-diagnosis, only half of the patients knew about cervical cancer. Even among those aware of cervical cancer, many assumed they were not at risk because they were not sexually active. Misdiagnosis was another common source of delay experienced by half of the patients. Once diagnosed, women faced multiple-month waits for referrals, and, once in treatment, broken equipment and shortages of hospital beds resulted in additional delays. Barriers to therapeutic treatment included a lack of housing and travel funds. Patient-provider communication of cancer diagnosis was often lacking. CONCLUSIONS: In-service provider training should be intensified and should include discussions of cervical cancer symptoms. Better distribution of screening and diagnostic supplies to lower-level facilities and better maintenance of treatment equipment at tertiary facilities are also a priority. Expanded cervical cancer health education should focus on stigma reduction and emphasize a broad, wide-spread risk of cervical cancer.

Cervical cancer is the second most commonly diagnosed cancer among Ethiopian women, killing an estimated 4700 women each year. This study aimed to assess patient and provider experiences in receiving and providing cervical cancer screening, diagnosis, and treatment. We interviewed 30 midlevel providers and ten women receiving care and held a focus group discussion with five women who were receiving treatment or who had recently completed treatment. Patients reported bottlenecks and delays at each stage of care. Low perception of risk, high stigma, and a lack of knowledge about cervical cancer among both providers and patients, were significant sources of delay in initiating care. Few patients had been aware of cervical cancer before they were diagnosed and of those who were aware, many assumed that they were not at risk because they were not sexually active. Misdiagnosis was another common source of delay. Once diagnosed correctly, women faced multiple-month delays after referrals, and, once in treatment, broken equipment and a shortage of hospital beds resulted in additional delays. The most frequently mentioned barriers to care were a lack of housing and travel funds while receiving treatment in the capital. Patient-provider communication of cancer diagnosis was often poor. Our findings suggest the need to intensify in-service training for providers, focusing initially on alerting them to cervical cancer symptoms. Better distribution of screening and diagnostic supplies to lower-level facilities and better maintenance of treatment equipment at tertiary facilities should also be a priority.

Outsiders, insiders, and intermediaries: village health teams' negotiation of roles to provide high quality sexual, reproductive and HIV care in Nakaseke, Uganda.

BACKGROUND: Community health workers, known as Village Health Teams (VHTs) in Uganda, play a central role in increasing access to community-based health services. The objective of this research is to explore tensions that may emerge as VHTs navigate multiple roles as community members and care providers particularly when providing sensitive reproductive health and HIV care. METHODS: Twenty-five VHTs from a rural clinic in Uganda completed semi-structured interviews focused on experiences providing services. Interview questions focused on challenges VHTs face providing services and strategies for improving quality care. After translation from Luganda and transcription, interviews were analyzed using content analysis to identify emergent themes. RESULTS: Most VHTs were female (n = 16). The average age was 46, and average length of VHT work, 11 years. Analyses revealed that all VHTs capitalized upon the duality of their position, shifting roles depending upon context. Three themes emerged around VHTs' perceptions of their roles: community insiders, professional outsiders, and intermediaries. A caregiver "insider" role facilitated rapport and discussion of sensitive issues. As community members, VHTs leveraged existing community structures to educate clients in familiar settings such as "drinking places". However, this role posed challenges as some VHTs felt compelled to share their own resources including food and transport money. Occupying a professional outsider role offered VHTs respect. Their specialized knowledge gave them authority to counsel others on effective forms of family planning. However, some VHTs faced opposition, suspicions about their motives, and violence in this role. In balancing these two roles, the VHTs adopted a third as intermediaries, connecting the community to services in the formalized health care system. Participants suggested that additional training, ongoing supervision, and the opportunity to collaborate with other VHTs would help them better navigate their different roles and, ultimately, improve the quality of service. CONCLUSIONS: As countries scale up family planning and HIV services using VHTs, supportive supervision and ethical dilemma training are recommended so VHTs are prepared for the challenges of assuming multiple roles within communities.

Knowledge and use of family planning among men in rural Uganda.

BACKGROUND: Unmet need for family planning exceeds 33% in Uganda. One approach to decreasing unmet need is promoting male involvement in family planning. Male disapproval of use of family planning by their female partners and misconceptions about side effects are barriers to family planning globally and in Uganda in particular. Researchers have conducted a number of qualitative studies in recent years to examine different aspects of family planning among Ugandan men. The present study aimed to quantify men's knowledge of family planning in rural Uganda to understand how better to involve men in couples' contraceptive decision-making, particularly in low-resource settings. METHODS: Data were derived from in-person, researcher-administered surveys of men in a rural agrarian district in Uganda (N = 178). Participant demographics and knowledge of family planning methods, side effects, and use were queried. Descriptive statistics were used for analysis. RESULTS: Men were 34 years of age on average (range 18-71) and about half (56%) had a primary school education or less. Ninety-eight percent reported any knowledge of family planning, with 73% of men reporting obtaining information via radio and only 43% from health workers. The most common method known by men was the male condom (72%), but more than half also knew of injections (54%) and pills (52%). Relatively few men reported knowing about the most effective reversible contraceptive methods, intrauterine devices and implants (both 16%). Men identified many common contraceptive side-effects, such as vaginal bleeding (31%), and misconceptions about side effects, such as increased risk of infertility and birth defects, were relatively uncommon (both < 10%). About half of all men reported ever using a family planning method (53%), and 40% reported current use. CONCLUSIONS: This study's quantitative results build on those of recent qualitative studies and provide information about the types of family planning information men are lacking and avenues for getting this information to them.

Professional Pragmatism and Abortion Stigma: Assessing the Performance of the Stigmatizing Attitudes, Beliefs and Actions Scale (SABAS) among Ethiopian Midwives.

This study assessed the applicability to medical professionals in Ethiopia of an abortion stigma assessment tool developed for community members, and examined the relationship between stigma and willingness to provide safe abortion care (SAC). The Stigmatizing Attitudes, Beliefs and Actions Scale (SABAS) was fielded to a convenience sample of 397 Ethiopian midwives. Scale reliability and validity were assessed, and associations were examined using multivariate linear and logistic regression. Levels of stigma were low compared to those reported elsewhere, and 49% of midwives were willing to provide SAC. The revised SABAS was reliable (alpha = 0.82), but items did not group into SABAS' conceptual categories, and some had limited face validity. SABAS scores had a small but significant negative association with willingness to provide SAC (OR=0.95, p < 0.05), with negative stereotyping subscale items most predictive. SABAS' limitations found here suggest the need for an adapted scale for medical professionals.

Medical society engagement in contentious policy reform: the Ethiopian Society for Obstetricians and Gynecologists (ESOG) and Ethiopia's 2005 reform of its Penal Code on abortion.

Unsafe abortion is one of the three leading causes of maternal mortality in low-income countries; however, few countries have reformed their laws to permit safer, legal abortion, and professional medical associations have not tended to spearhead this type of reform. Support from a professional association typically carries more weight than does that from an individual medical professional. However, theory predicts and the empirical record largely reveals that medical associations shy from engagement in conflictual policymaking such as on abortion, except when professional autonomy or income is at stake. Using interviews with 10 obstetrician-gynaecologists and 44 other leaders familiar with Ethiopia's reproductive health policy context, as well as other primary and secondary sources, this research examines why, counter to theoretical expectations from the sociology of medical professions literature and experience elsewhere, the Ethiopian Society of Obstetricians & Gynecologists (ESOG) actively supported reform of national law on abortion. ESOG leadership participation was motivated by both individual and ESOG's organizational commitments to reducing maternal mortality and also by professional training and work experience. Further, typical constraints on medical society involvement in policymaking were relaxed or removed, including those related to ESOG's organizational structure and history, and to political environment. Findings do not contradict theory positing medical society avoidance of socially conflictual health policymaking, but rather identify how the expected restrictions were less present in Ethiopia, facilitating medical society participation. Results can inform efforts to encourage medical society participation in policy reform to improve women's health elsewhere in sub-Saharan Africa.

Midwives' and patients' perspectives on disrespect and abuse during labor and delivery care in Ethiopia: a qualitative study.

BACKGROUND: It is increasingly recognized that disrespect and abuse of women during labor and delivery is a violation of a woman's rights and a deterrent to the use of life-saving, facility-based labor and delivery services. In Ethiopia, rates of skilled birth attendance are still only 28% despite a recent dramatic national scale up in the numbers of trained providers and facilities. Concerns have been raised that womens' perceptions of poor quality of care and fear of mistreatment might contribute to this low utilization. This study examines the experiences of disrespect and abuse in maternal care from the perspectives of both providers and patients. METHODS: We conducted 45 in-depth interviews at four health facilities in Debre Markos, Ethiopia with midwives, midwifery students, and women who had given birth within the past year. Students and providers also took a brief quantitative survey on patients' rights during labor and delivery and responded to clinical scenarios regarding the provision of stigmatized reproductive health services. RESULTS: We find that both health care providers and patients report frequent physical and verbal abuse as well as non-consented care during labor and delivery. Providers report that most abuse is unintended and results from weaknesses in the health system or from medical necessity. We uncovered no evidence of more systematic types of abuse involving detention of patients, bribery, abandonment or ongoing discrimination against particular ethnic groups. Although health care providers showed good basic knowledge of confidentiality, privacy, and consent, training on the principles of responsive and respectful care, and on counseling, is largely absent. Providers indicated that they would welcome related practical instruction. Patient responses suggest that women are aware that their rights are being violated and avoid facilities with reputations for poor care. CONCLUSIONS: Our results suggest that training on respectful care, offered in the professional ethics modules of the national midwifery curriculum, should be strengthened to include greater focus on counseling skills and rapport-building. Our findings also indicate that addressing structural issues around provider workload should complement all interventions to improve midwives' interpersonal interactions with women if Ethiopia is to increase provision of respectful, patient-centered maternity care.

Personal Beliefs and Professional Responsibilities: Ethiopian Midwives' Attitudes toward Providing Abortion Services after Legal Reform.

In 2005, Ethiopia liberalized its abortion law and subsequently authorized midwives to offer abortion services. Using a 2013 survey of 188 midwives and 12 interviews with third-year midwifery students, this cross-sectional research examines midwives' attitudes toward abortion to understand their decisions about service provision. Most midwives were willing to provide abortion services. This willingness was positively and significantly related to clinical experience with abortion, but negatively and significantly related to religiosity, belief that providers have the right to refuse to provide services, and care of patients from periurban as opposed to rural areas. No significant relationship was found with perceptions of abortion stigma, years of work as a midwife, or knowledge of the law. Interview data suggest complex dynamics underlying midwives' willingness to offer services, including conflicts between professional norms and religious beliefs. Findings can inform Ethiopia's efforts to reduce maternal mortality through task-shifting to midwives and can aid other countries that are confronting provider shortages and high levels of maternal mortality and morbidity, particularly due to unsafe abortion.