Models of palliative care for under-served populations in high-income countries: a scoping review protocol.

OBJECTIVE: The objective of this scoping review is to describe models of palliative care for under-served populations in high-income countries, defined as adults of culturally and linguistically diverse communities, low socioeconomic status, and/or residing in rural areas. INTRODUCTION: Models of palliative care are processual, referring to the way palliative care services are delivered as people experience a condition, injury, or event. The aim of these models is to ensure people get the right care, at the right time, by the right team, in the right place. Evidence suggests there is a wide variety of models of palliative care, but what is not known is how these models can vary to meet the needs of under-served populations. INCLUSION CRITERIA: This scoping review will consider articles that focus on models of palliative care for under-served populations, irrespective of sex, age, or primary diagnosis. METHODS: MEDLINE (Ovid), Embase (Ovid), PsycINFO (Ovid), Emcare (Ovid), CINAHL (EBSCOhost), and Scopus will be searched for articles, irrespective of language, published from 2014. Two independent reviewers will screen titles and abstracts, followed by a full-text review of potentially relevant articles. Discrepancies will be reconciled with another reviewer. Two independent reviewers will extract data from included articles using a data extraction tool developed for this review. Results will be tabulated and/or presented diagrammatically, as well as summarized to explicitly address the objective of the review. REVIEW REGISTRATION: Open Science Framework osf.io/x4ky3.

Concomitant illnesses in pregnancy in Indonesia: A health systems analysis at a District level.

BACKGROUND: In LMICs, including Indonesia, there is a rising burden of non-communicable diseases (NCDs) with a prevailing burden of infectious diseases, including among pregnant women. The Indonesian health system faces significant challenges to provide effective care for infectious diseases, and even more so, NCDs. This is concerning due to the greater vulnerability of pregnant women to complications caused by concomitant illnesses (NCDs and infectious diseases), and the need for complex, integrated healthcare between maternal care and other health services. METHODS: The objective of this study was to understand supporting factors and challenges of the health system to providing care for concomitant illnesses in pregnancy and how it may be improved. Semi-structured interviews were conducted with sixteen key stakeholders, including health providers and health service managers, involved in maternal healthcare for concomitant illnesses at a District level in Indonesia. The study was conducted in Kutai Kartanegara District of East Kalimantan. Analysis was conducted using framework analysis to identify themes from transcripts. RESULTS: Supporting factors of the health system to provide care for concomitant illness in pregnancy included collaboration between health providers and health services, availability of screening and diagnostic tools, and access to universal healthcare coverage and financial subsidies. Common challenges included knowledge and awareness of concomitant illnesses among health providers, competency to diagnose and/or manage concomitant illnesses, and inappropriate referrals. Suggested improvements identified to address these gaps included increasing education and refresher training for healthcare providers and strengthening referrals between primary and hospital care. CONCLUSIONS: The findings identified gaps in the health system to provide care for concomitant illnesses in pregnancy in Indonesia that need to be strengthened. More evidence-based research is needed to guide the implementation of policy and practice interventions for the health system to deal with a broader range of concomitant illnesses in pregnancy, particularly NCDs.

Chronic hepatitis B management in six South Australian Aboriginal community controlled health services.

BACKGROUND: Chronic hepatitis B is a significant public health issue; however, there is limited understanding of the engagement in primary health care of Aboriginal people living with chronic hepatitis B (CHB). METHODS: To better understand the management of CHB, diagnostic reports and case note audits were conducted in six South Australian Aboriginal community controlled health services. The audits covered the initial assessment, CHB monitoring, and hepatocellular carcinoma screening. The initial assessment was reviewed by auditing client clinical records for the first 12months from the date of diagnosis, whereas CHB monitoring and hepatocellular carcinoma screening were determined by auditing a 12-month sample period (January to December 2019). Associations with CHB monitoring were determined using a Chi-squared test and Fisher's exact test P -values, as appropriate. RESULTS: There were 50 current clients with a diagnosis of CHB at the time of the audit (January 2020). Testing was incomplete for the initial assessment, CHB monitoring and hepatocellular carcinoma screening. There were significant associations between the increased likelihood of accessing monitoring and the number of times a person attended an Aboriginal community controlled health service, accessing care in a more remote region, having a documented recall and having a GP management plan containing CHB. CONCLUSION: Through providing evidence of significant associations between having a recall set and GP management plans with increased uptake of disease monitoring, this study has highlighted areas for improvement in clinical management.

Indicator-activities to apply primary health care principles in national or large-scale community health worker programs in low-and middle-income countries: a Delphi exercise.

INTRODUCTION: Primary Health Care (PHC) gained considerable momentum in the past four decades and led to improved health outcomes across a wide variety of settings. In low-and middle-income countries (LMICs), national or large-scale Community Health Worker Programs (CHWPs) are considered as vehicles to incorporate PHC principles into healthcare provision and are an essential aspect of the PHC approach to achieve health for all and sustainable development goals. The success of CHWPs is rooted in the application of PHC principles. However, there is evidence that shows patchy implementation of PHC principles across national CHWPs in LMICs. This may reflect the lack of information on what activities would illustrate the application of these principles in CHWPs. This study aimed to identify a set of core/indicator-activities that reflect the application of PHC principles by CHWPs in LMICs. METHODS: A two-round modified Delphi study was undertaken with participants who have extensive experience in planning, implementation and evaluation of CHWPs. Survey design and analysis was guided by the four PHC principles namely Universal Health Coverage, Community Participation, Intersectoral Coordination and Appropriateness. Responses were collected using a secure online survey program (survey monkey). In round one, participants were asked to list 'core activities' that would reflect the application of each PHC principle and its sub-attributes and challenges to apply these principles in CHWPs. In round two, participants were asked to select whether they agree or disagree with each of the activities and challenges. Consensus was set a priori at 70% agreement of participants for each question. RESULTS: Seventeen participants from 15 countries participated in the study. Consensus was reached on 59 activities reflecting the application of PHC principles by CHWPs. Based on participants' responses, a set of 29 indicator-activities for the four PHC principles was developed with examples for each indicator-activity. CONCLUSION: These indicator-activities may provide guidance on how PHC principles can be implemented in CHWPs. They can be used in the development and evaluation of CHWPs, particularly in their application of PHC principles. Future research may focus on testing the utility of indicator-activities on CHWPs in LMICs.

The impact of non-pharmaceutical interventions on COVID-19 cases in South Australia and Victoria.

OBJECTIVE: To assess the impact of different non-pharmaceutical interventions (NPIs) on COVID-19 cases across Victoria and South Australia. METHODS: Poisson regression models were fit to examine the effect of NPIs on weekly COVID-19 case numbers. RESULTS: Mask-wearing in Victoria had a pronounced lag effect of two weeks with an incidence rate ratio (IRR) of 0.27 (95%CI 0.26-0.29). Similarly, the effect of border closure (IRR 0.18; 95%CI 0.14-0.22) in South Australia and lockdown (IRR 0.88; 95%CI 0.86-0.91) in Victoria showed a decrease in incidence two weeks after the introduction of these interventions. CONCLUSIONS: With the ongoing COVID-19 pandemic, varying levels of vaccination coverage rates and threats from variants of concern, NPIs are likely to remain in place. It is thus important to validate the effectiveness and timing of different interventions for disease control, as those that are more restrictive such as border control and lockdown can have an enormous impact on society. IMPLICATIONS FOR PUBLIC HEALTH: Low case numbers and deaths in Australia's first wave of COVID-19 are thought to be due to the timely use of interventions. The observed two-week lag effect associated with a decrease in incidence provides justification for early implementation of NPIs for COVID-19 management and future pandemics.

Application of primary healthcare principles in national community health worker programmes in low-income and middle-income countries: a scoping review.

OBJECTIVE: To identify which primary healthcare (PHC) principles are reflected in the implementation of national community health worker (CHW) programmes and how they may contribute to the outcomes of these programmes in the context of low-income and middle-income countries (LMICs). DESIGN: Scoping review. DATA SOURCES: A systematic search was conducted through PubMed, CINAHL, EMBASE and Scopus databases. ELIGIBILITY CRITERIA: The review considered published primary studies on national programmes, projects or initiatives using the services of CHWs in LMICs focused on maternal and child health. We included only English language studies. Excluded were programmes operated by non-government organisations, study protocols, reviews, commentaries, opinion papers, editorials and conference proceedings. DATA EXTRACTION AND SYNTHESIS: We reviewed the application of four PHC principles (universal health coverage, community participation, intersectoral coordination and appropriateness) in the CHW programme's objectives, implementation and stated outcomes. Data extraction was undertaken systematically in an excel spreadsheet while the findings were synthesised in a narrative manner. The quality appraisal of the selected studies was not performed in this scoping review. RESULTS: From 1280 papers published between 1983 and 2019, 26 met the inclusion criteria. These 26 papers included 14 CHW programmes from 13 LMICs. Universal health coverage and community participation were the two commonly reported PHC principles, while intersectoral coordination was generally missing. Similarly, the cultural acceptability aspect of the principle of appropriateness was present in all programmes as these programmes select CHWs from within the communities. Other aspects, particularly effectiveness, were not evident. CONCLUSION: The implementation of PHC principles across national CHW programmes in LMICs is patchy. For comprehensiveness and improved health outcomes, programmes need to incorporate all attributes of PHC principles. Future research may focus on how to incorporate more attributes of PHC principles while implementing national CHW programmes in LMICs. Better documentation and publications of CHW programme implementation are also needed.

Incidence of concomitant illnesses in pregnancy in Indonesia: Estimates from 1990-2019, with projections to 2030.

BACKGROUND: 'Indirect' causes of maternal death including concomitant illnesses such as infectious and non-communicable diseases (NCDs), accounted for 23% of maternal deaths in Indonesia in 2010. Reproductive-age women in Indonesia face a "double burden" of disease with increasing rates of NCDs and persisting rates of infectious disease. However, there is a lack of data on the burden of these diseases in pregnancy. The aim of this study was to estimate incidence of concomitant illnesses among pregnant women in Indonesia from 1990-2030. METHODS: Publicly available data was accessed including incidence of concomitant illnesses in Indonesian reproductive-age women, population data and crude birth rate data from 1990-2019, and formed basis for projections to 2030. A dataset of estimates for all variables was generated for each year and sampled from a binomial distribution. Using these estimates, pregnancy estimates and incidence in pregnant women were calculated. A cubic splines model was fitted to generate estimates of incidence of concomitant illnesses in pregnancy. FINDINGS: Past trends to 2019 show a decline in incident cases of infectious diseases except for HIV/AIDs, and an increase in most NCDs. In 2019, the most common disease was sexually transmitted infections. From 2020-2030, incidences of diabetes and lower respiratory infections are estimated to continue to increase. INTERPRETATION: With an increasing incidence of NCDs and high-incidence of infectious diseases in pregnancy, Indonesian policymakers and stakeholders should consider what evidence-based strategies and interventions are best to reduce potential impacts of concomitant illnesses on pregnancy outcomes. FUNDING: Australian Government Research Training Program Scholarship.

Application of primary health care principles in national community health worker programs in low- and middle-income countries: a scoping review protocol.

OBJECTIVE: This scoping review aims to map the available literature on the application of primary health care principles as reflected in the implementation of national-level community health worker programs in low- and middle-income countries. INTRODUCTION: There is extensive literature on how community health workers have been used to improve the health status of disadvantaged populations, especially in low- and middle-income countries. Established under the primary health care principles, national community health worker programs were expected to adopt and promote these principles to achieve improvements in health outcomes. However, there is limited evidence of the extent to which primary health care principles have been applied in the implementation of national community health worker programs. INCLUSION CRITERIA: The concept to be mapped is the application of primary health care principles in the implementation of national community health worker programs in low- and middle-income countries. Quantitative, qualitative, and mixed methods study designs will be included. Only English-language articles published from September 1978 to the present will be included. Study protocols, narrative reviews, systematic and scoping reviews, commentaries, text and opinion papers, viewpoints, editorials, and conference proceedings/abstracts and correspondences will be excluded. The programs operated by non-governmental organizations and articles not involving community health workers will also be excluded. METHODS: Key information sources to be searched include MEDLINE, CINAHL, Embase, and Scopus. Two reviewers will independently screen the titles and abstracts against the inclusion criteria. The data charting will include specific details about the concept, context, study methods, and key findings relevant to the review question. Data will be presented in diagrammatic or tabular form accompanied by a narrative summary.

Structural Quality of Services and Use of Family Planning Services in Primary Health Care Facilities in Ethiopia. How Do Public and Private Facilities Compare?

BACKGROUND: Family planning (FP) is among the important interventions that reduce maternal mortality. Poor quality FP service is associated with lower services utilisation, in turn undermining the efforts to address maternal mortality. There is currently little research on the quality of FP services in the private sector in Ethiopia, and how it compares to FP services in public facilities. METHODS: A secondary data analysis of two national surveys, Ethiopia Services Provision Assessment Plus Survey 2014 and Ethiopian Demographic and Health Survey 2016, was conducted. Data from 1094 (139 private, 955 public) health facilities were analysed. In total, 3696 women were included in the comparison of users' characteristics. Logistic regression was conducted. Facility type (public vs. private) was the key exposure of interest. RESULTS: The private facilities were less likely to have implants (Adjusted Odds Ratio (AOR) = 0.06; 95% Confidence Interval (CI): 0.03, 0.12), trained FP providers (AOR = 0.23; 95% CI: 0.14, 0.41) and FP guidelines/protocols (AOR = 0.33; 95% CI: 0.19, 0.54) than public facilities but were more likely to have functional cell phones (AOR = 8.20; 95% CI: 4.95, 13.59) and water supply (AOR = 3.37; 95% CI: 1.72, 6.59). CONCLUSION: This study highlights the need for strengthening both private and public facilities for public-private partnerships to contribute to increased FP use and better health outcomes.

Healthcare providers' perspectives on use of the national guideline for family planning services in Amhara Region, Ethiopia: a qualitative study.

OBJECTIVE: To explore healthcare providers' views on barriers to and facilitators of use of the national family planning (FP) guideline for FP services in Amhara Region, Ethiopia. DESIGN: Qualitative study. SETTING: Nine health facilities including two hospitals, five health centres and two health posts in Amhara Region, Northwest Ethiopia. PARTICIPANTS: Twenty-one healthcare providers working in the provision of FP services in Amhara Region. PRIMARY AND SECONDARY OUTCOME MEASURES: Semistructured interviews were conducted to understand healthcare providers' views on barriers to and facilitators of the FP guideline use in the selected FP services. RESULTS: While the healthcare providers' views point to a few facilitators that promote use of the guideline, more barriers were identified. The barriers included: lack of knowledge about the guideline's existence, purpose and quality, healthcare providers' personal religious beliefs, reliance on prior knowledge and tradition rather than protocols and guidelines, lack of availability or insufficient access to the guideline and inadequate training on how to use the guideline. Facilitators for the guideline use were ready access to the guideline, convenience and ease of implementation and incentives. CONCLUSIONS: While development of the guideline is an important initiative by the Ethiopian government for improving quality of care in FP services, continued use of this resource by all healthcare providers requires planning to promote facilitating factors and address barriers to use of the FP guideline. Training that includes a discussion about healthcare providers' beliefs and traditional practices as well as other factors that reduce guideline use and increasing the sufficient number of guideline copies available at the local level, as well as translation of the guideline into local language are important to support provision of quality care in FP services.

An overview of the general practice nurse workforce in Australia, 2012-15.

Several surveys of the general practice nurse (GPN) workforce have been undertaken in Australia over the last decade, but they have limitations, which mean that the workforce is not well-understood. The aim of this study is to describe the profile of the GPN workforce using the dataset available through the Australia Health Practitioner Registration Agency and to explore how it differs from the non-GPN nursing workforce, and if this workforce is changing over time. Data from labour force surveys conducted from 2012 to 2015 were used. Variables examined were age group, gender, remoteness area, hours worked, nurse type (enrolled (EN) or registered (RN)), years in the workforce and also intended years of work before exiting the workforce. When compared with the broader nursing workforce, a greater proportion of GPNs in 2015 were older (60 v. 51%), worked part-time (65 v. 48%) and worked in regional areas (35 v. 26%). Additionally, the characteristics of GPNs has changed between 2012 and 2015, with an increased proportion of younger nurses, more registered nurses and fewer working in remote areas. To ensure a sustainable workforce, particularly in rural and remote areas, strategies to recruit and retain this workforce will be needed.

Collaborative pharmacist prescribing within the opioid substitution treatment program in South Australia: Patient and pharmacist views.

There is a shortage of medical practitioners able and/or willing to prescribe OST. This qualitative study investigated an alternative model of care where by pharmacists co-prescribed with an accredited doctor for OST patients. Semi-structured face-to-face interviews with 14 OST patients were conducted at a state government drug and alcohol clinic about their views on pharmacist prescribing OST for them. In the second phase of the study, three focus group interviews with 18 pharmacists were conducted to explore their views on a policy proposal which would allow them to co-prescribe for OST patients. Transcripts were analysed using the five-step framework approach with the support of the software package NVivo. In general, both patients and pharmacists supported co-prescribing. Improved patient continuity of care and convenience were regarded as the main benefits of having a pharmacist co-prescriber. Continued doctor involvement with patient was supported under a co-prescribing model, but not all pharmacists may desire or be suitable to fulfil the role of a co-prescriber. Changes to health care relationships and provisions to ensure adequate support of pharmacist co-prescribers were important consideration factors in moving forward with this proposed new model of care.

The never ending road: improving, adapting and refining a needs-based model to estimate future general practitioner requirements in two Australian states.

Background: Health workforce planning models have been developed to estimate the future health workforce requirements for a population whom they serve and have been used to inform policy decisions. Objectives: To adapt and further develop a need-based GP workforce simulation model to incorporate current and estimated geographic distribution of patients and GPs. Methods: A need-based simulation model that estimates the supply of GPs and levels of services required in South Australia (SA) was adapted and applied to the Western Australian (WA) workforce. The main outcome measure was the differences in the number of full-time equivalent (FTE) GPs supplied and required from 2013 to 2033. Results: The base scenario estimated a shortage of GPs in WA from 2019 onwards with a shortage of 493 FTE GPs in 2033, while for SA, estimates showed an oversupply over the projection period. The WA urban and rural models estimated an urban shortage of GPs over this period. A reduced international medical graduate recruitment scenario resulted in estimated shortfalls of GPs by 2033 for WA and SA. The WA-specific scenarios of lower population projections and registrar work value resulted in a reduced shortage of FTE GPs in 2033, while unfilled training places increased the shortfall of FTE GPs in 2033. Conclusions: The simulation model incorporates contextual differences to its structure that allows within and cross jurisdictional comparisons of workforce estimations. It also provides greater insights into the drivers of supply and demand and the impact of changes in workforce policy, promoting more informed decision-making.

The general practice nurse workforce: Estimating future supply

BACKGROUND: General practice nurses (GPNs) form an important component of the general practice workforce in Australia. Despite this, there is limited research on estimating their future supply. This study aims to estimate the future GPN supply and the impact of a range of policy and non-policy changes on workforce balances. METHOD: A simulation model of the GPN workforce over the period 2012­25 was developed, with scenario analysis used to assess the effects of policy and non­policy scenarios. RESULTS: The baseline scenario estimated a shortage of 814 full-time GPNs by 2025. The non-policy single scenarios all projected shortages by 2025. The worst-case scenario was reduced working hours and best-case scenario was the retention scenario. DISCUSSION: Over the 13-year period considered, the Australian practice nurse workforce is predicted to move into a position of shortage. Retention and recruitment policies are shown to be effective in addressing these shortages.

Client and facility level determinants of quality of care in family planning services in Ethiopia: Multilevel modelling.

INTRODUCTION: Over the last two decades, while contraceptive use has improved in Ethiopia, the contraceptive prevalence rate remains low. In addition to socio-demographic and cultural factors, the quality of care in Family Planning (FP) services is an important determining factor of FP utilization. However, little research exists on the determinants of quality of care in FP services in Ethiopia. This study aims to identify the client and facility level determinants of quality of care in FP services in Ethiopia. METHODS: This study was based on the first Ethiopian Services Provision Assessment Plus (ESPA+) survey conducted in 2014. A total of 1247 clients nested in 374 health facilities were included in the analysis. Multilevel mixed-effects logistic regression modelling was conducted. The outcome variable, client satisfaction, was created using polychoric principal component analysis using eleven facets that reflect client satisfaction. RESULTS: The results showed that both client-level and facility-level factors were associated with quality of care in FP services in Ethiopia. At the client-level; provision of information on potential side effects of contraceptive method (AOR = 5.22, 95% CI: 2.13-12.80), and number of history and physical assessments (AOR = 1.19, 95% CI: 1.03-1.34) were positively associated with client satisfaction, whereas waiting times of 30 minutes to two hours (AOR = 0.11, 95% CI: 0.03-0.33) was negatively associated with client satisfaction. At the facility-level; urban location (AOR = 4.61, 95% CI: 1.04-20.58), and availability of FP guidelines/protocols for providers (AOR = 4.90, 95% CI: 1.19-20.19) had positive significant effect on client satisfaction. CONCLUSION: Quality improvement programs in FP services in Ethiopia should focus on shortening waiting times and provision of information about the potential side effects of contraceptive methods. It is also important to improve health providers' skills in thorough client history taking and physical assessment. Further distribution and implementation of best practice guidelines for providers working in the FP services must be a priority.

What will make a difference? Assessing the impact of policy and non-policy scenarios on estimations of the future GP workforce.

BACKGROUND: Health workforce planning is based on estimates of future needs for and supply of health care services. Given the pipeline time lag for the training of health professionals, inappropriate workforce planning or policies can lead to extended periods of over- or under-supply of health care providers. Often these policy interventions focus on one determinant of supply and do not incorporate other determinants such as changes in population health which impact the need for services. The aim of this study is to examine the effect of the implementation of various workforce policies on the estimated future requirements of the GP workforce, using South Australia as a case study. This is examined in terms of the impact on the workforce gap (excess or shortage), the cost of these workforce policies, and their role in addressing potential non-policy-related future scenarios. METHODS: An integrated simulation model for the general practice workforce in South Australia was developed, which determines the supply and level of services required based on the health of the population over a projection period 2013-2033. The published model is used to assess the effects of various policy and workforce scenarios. For each policy scenario, associated costs were estimated and compared to baseline costs with a 5% discount rate applied. RESULTS: The baseline scenario estimated an excess supply of GPs of 236 full-time equivalent (FTE) in 2013 but this surplus decreased to 28 FTE by 2033. The estimates based on single policy scenarios of role substitution and increased training positions continue the surplus, while a scenario that reduces the number of international medical graduates (IMGs) recruited estimated a move from surplus to shortage by 2033. The best-case outcome where the workforce achieves balance by 2023 and remains balanced to 2033, arose when GP participation rates (a non-policy scenario) were combined with the policy levers of increased GP training positions and reduced IMG recruitment. The cost of each policy varied, with increased role substitution and reduced IMG recruitment resulting in savings (AUD$752,946,586 and AUD$3,783,291 respectively) when compared to baseline costs. Increasing GP training costs over the projection period would cost the government an additional AUD$12,719,798. CONCLUSIONS: Over the next 20 years, South Australia's GP workforce is predicted to remain fairly balanced. However, exogenous changes, such as increased demand for GP services may require policy intervention to address associated workforce shortfalls. The workforce model presented in this paper should be updated at regular intervals to inform the need for policy intervention.

Trends and causes of maternal mortality in Ethiopia during 1990-2013: findings from the Global Burden of Diseases study 2013.

BACKGROUND: Maternal mortality is noticeably high in sub-Saharan African countries including Ethiopia. Continuous nationwide systematic evaluation and assessment of the problem helps to design appropriate policy and strategy in Ethiopia. This study aimed to investigate the trends and causes of maternal mortality in Ethiopia between 1990 and 2013. METHODS: We used the Global Burden of Diseases and Risk factors (GBD) Study 2013 data that was collected from multiple sources at national and subnational levels. Spatio-temporal Gaussian Process Regression (ST-GPR) was applied to generate best estimates of maternal mortality with 95% Uncertainty Intervals (UI). Causes of death were measured using Cause of Death Ensemble modelling (CODEm). The modified UNAIDS EPP/SPECTRUM suite model was used to estimate HIV related maternal deaths. RESULTS: In Ethiopia, a total of 16,740 (95% UI: 14,197, 19,271) maternal deaths occurred in 1990 whereas there were 15,234 (95% UI: 11,378, 19,871) maternal deaths occurred in 2013. This finding shows that Maternal Mortality Ratio (MMR) in Ethiopia was still high in the study period. There was a minimal but insignificant change of MMR over the last 23 years. The results revealed Ethiopia is below the target of Millennium Development Goals (MGDs) related to MMR. The top five causes of maternal mortality in 2013 were other direct maternal causes such as complications of anaesthesia, embolism (air, amniotic fluid, and blood clot), and the condition of peripartum cardiomyopathy (25.7%), complications of abortions (19.6%), maternal haemorrhage (12.2%), hypertensive disorders (10.3%), and maternal sepsis and other maternal infections such as influenza, malaria, tuberculosis, and hepatitis (9.6%). Most of the maternal mortality happened during the postpartum period and majority of the deaths occurred at the age group of 20-29 years. Overall trend showed that there was a decline from 708 per 100,000 live births in 1990 to 497 per 100,000 in 2013. The annual rate of change over these years was -1.6 (95% UI: -2.8 to -0.3). CONCLUSION: The findings of the study highlight the need for comprehensive efforts using multisectoral collaborations from stakeholders for reducing maternal mortality in Ethiopia. It is worthwhile for policies to focus on postpartum period.

Rethinking registrar attributes for Australian rural general practice training.

OBJECTIVE: Despite increases in Commonwealth funded general practice (GP) Registrar training positions, workforce trends continue to show geographical maldistribution. This study aimed to identify Registrar attributes which describe a cohort choosing to work in rural practice. DESIGN: Cross-sectional self-report questionnaire for socio-demographics, prior training, current training pathway, measures of personality and resilience. PARTICIPANTS AND SETTING: GP Registrars (N = 452) training in either the general or rural pathways of three Registered Training Providers in three states, or training through the Australian College of Rural and Remote Medicine's independent pathway. MAIN OUTCOME MEASURE: Ordinal logistic regression tested the impact of key variables on the likelihood that Registrars would settle in rural practice. Univariate analysis explored differences between groups and effects of variables. RESULTS: A significantly increased interest in rural practice was to found to exist among registrars who were male, identified themselves as being rural, had a partner who identified as being rural, were enrolled in a rural training pathway and had high levels of Cooperativeness. CONCLUSION: We present a discriminating model combining socio-demographics, prior training and personality variables which challenges Australia to rethink Registrar attributes when training for rural general practice. With significant changes about to occur to GP training in Australia, this paper highlights the need for a more holistic approach which considers personal attributes such as Cooperativeness, rural identity and provision of geographically focused rural training pipelines to encourage Registrars to bond to individual rural communities and further develop their personal connectedness to country life and rural medical practice.

Factors Determining Quality of Care in Family Planning Services in Africa: A Systematic Review of Mixed Evidence.

BACKGROUND: Improving use of family planning services is key to improving maternal health in Africa, and provision of quality of care in family planning services is critical to support higher levels of contraceptive uptake. The objective of this systematic review was to synthesize the available evidence on factors determining the quality of care in family planning services in Africa. METHODS: Quantitative and qualitative studies undertaken in Africa, published in English, in grey and commercial literature, between 1990 and 2015 were considered. Methodological quality of included studies was assessed using standardized tools. Findings from the quantitative studies were summarized using narrative and tables. Client satisfaction was used to assess the quality of care in family planning services in the quantitative component of the review. Meta-aggregation was used to synthesize the qualitative study findings. RESULTS: From 4334 records, 11 studies (eight quantitative, three qualitative) met the review eligibility criteria. The review found that quality of care was influenced by client, provider and facility factors, and structural and process aspects of the facilities. Client's waiting time, provider competency, provision/prescription of injectable methods, maintaining privacy and confidentiality were the most commonly identified process factors. The quality of stock inventory was the most commonly identified structural factor. The quality of care was also positively associated with privately-owned facilities. The qualitative synthesis revealed additional factors including access related factors such as 'pre-requisites to be fulfilled by the clients and cost of services, provider workload, and providers' behaviour. CONCLUSION: There is limited evidence on factors determining quality of care in family planning services in Africa that shows quality of care is influenced by multiple factors. The evidence suggests that lowering access barriers and avoiding unnecessary pre-requisites for taking contraceptive methods are important to improve the quality of care in family planning services. Strategies to improve provider behavior and competency are important. Moreover, strategies that minimize client waiting time and ensure client confidentiality should be implemented to ensure quality of care in family planning services. However, no strong evidence based conclusions and recommendations may be drawn from the evidence. Future studies are needed to identify the most important factors associated with quality of care in family planning services in a wider range of African countries.

Factors determining quality of care in family planning services in Africa: a systematic review protocol.

REVIEW OBJECTIVE AND QUESTIONS: The objective of this systematic review is to identify and synthesize the best available quantitative and qualitative evidence to understand the factors determining quality of care in family planning services in Africa.The review question for the quantitative component of the review is:What factors, including facility, provider and client characteristics, are associated with quality of care in family planning services in Africa?The review question for the qualitative component of the review is:What are client and provider experiences and/or perceptions of factors that affect quality of care in family planning services in Africa?