An innovative intervention to improve respectful maternity care in three Districts in Ethiopia.

BACKGROUND: Mistreatment of women during facility-based childbirth is a major violation of human rights and often deters women from attending skilled birth. In Ethiopia, mistreatment occurs in up to 49.4% of mothers giving birth in health facilities. This study describes the development, implementation and results of interventions to improve respectful maternity care. As part of a national initiative to reduce maternal and perinatal mortality in Ethiopia, we developed respectful maternity care training module with three core components: testimonial videos developed from key themes identified by staff as experiences of mothers, skills-building sessions on communication and onsite coaching. Respectful maternity care training was conducted in February 2017 in three districts within three regions. METHODS: Facility level solutions applied to enhance the experience of care were documented. Safe Childbirth Checklist data measuring privacy and birth companion offered during labor and childbirth were collected over 27 months from 17 health centers and three hospitals. Interrupted time series and regression analysis were conducted to assess significance of improvement using secondary routinely collected programmatic data. RESULTS: Significant improvement in the percentage of births with two elements of respectful maternal care-privacy and birth companionship offered- was noted in one district (with short and long-term regression coefficient of 18 and 27% respectively), while in the other two districts, results were mixed. The short-term regression coefficient in one of the districts was 26% which was not sustained in the long-term while in the other district the long-term coefficient was 77%. Testimonial videos helped providers to see their care from their clients' perspectives, while quality improvement training and coaching helped them reflect on potential root causes for this type of treatment and develop effective solutions. This includes organizing tour to the birthing ward and allowing cultural celebrations. CONCLUSION: This study demonstrated effective way of improving respectful maternity care. Use of a multipronged approach, where the respectful maternity care intervention was embedded in quality improvement approach helped in enhancing respectful maternity care in a comprehensive manner.

Barriers to the uptake of community-based curative child health services in Ethiopia.

BACKGROUND: Uptake of services to treat newborns and children has been persistently low in Ethiopia, despite being provided free-of-charge by Health Extension Workers (HEWs). In order to increase the uptake of these services, the Optimizing the Health Extension Project was designed to be implemented in four regions in Ethiopia. This study was carried out to identify barriers to the uptake of these services and potential solutions to inform the project. METHODS: Qualitative data were collected in October and November 2015 in 15 purposely selected districts in four regions. We conducted 90 focus group discussions and 60 in-depth interviews reaching a total of 664 participants. Thematic analysis was used to identify key barriers and potential solutions. RESULTS: Five demand-side barriers to utilization of health services were identified. Misconceptions about illness causation, compounded with preference for traditional healers has affected service uptake. Limited awareness of the availability of free curative services for children at health posts; along with the prevailing perception that HEWs were providing preventive services only had constrained uptake. Geographic challenge that made access to the health post difficult was the other barrier. Four supply-side barriers were identified. Health post closure and drug stock-out led to inconsistent availability of services. Limited confidence and skill among HEWs and under-resourced physical facilities affected the service delivery. Study participants suggested demand creation solutions such as increasing community awareness on curative service availability and educating them on childhood illness causation. Maintaining consistent supplies and ensuring service availability; along with regular support to build HEWs' confidence were the suggested supply-side solutions. Creating community feedback mechanisms was suggested as a way of addressing community concerns on the health services. CONCLUSION: This study explored nine demand- and supply-side barriers that decreased the uptake of community-based services. It indicated the importance of increasing awareness of new services and addressing prevailing barriers that deprioritize health services. At the same time, supply-side barriers would have to be tackled by strengthening the health system to uphold newly introduced services and harness sustainable impact.

Barriers to the utilization of community-based child and newborn health services in Ethiopia: a scoping review.

The Ethiopian Federal Ministry of Health and partners have scaled up integrated community case management (iCCM) and community-based newborn care (CBNC), allowing health extension workers (HEWs) to manage the major causes of child and newborn death at the community level. However, low service uptake remains a key challenge. We conducted a scoping review of peer-reviewed and grey literature to assess barriers to the utilization of HEW services and to explore potential solutions. The review, which was conducted to inform the Optimizing the Health Extension Program project, which aimed to increase the utilization of iCCM and CBNC services, included 24 peer-reviewed articles and 18 grey literature documents. Demand-side barriers to utilization included lack of knowledge about the signs and symptoms of childhood illnesses and danger signs; low awareness of curative services offered by HEWs; preference for home-based care, traditional care, or religious intervention; distance, lack of transportation and cost of care seeking; the need to obtain husband's permission to seek care and opposition of traditional or religious leaders. Supply-side barriers included health post closures, drug stockouts, disrespectful care and limited skill and confidence of HEWs, particularly with regard to the management of newborn illnesses. Potential solutions included community education and demand generation activities, finding ways to facilitate and subsidize transportation to health facilities, engaging family members and traditional and religious leaders, ensuring consistent availability of services at health posts and strengthening supervision and supply chain management. Both demand generation and improvement of service delivery are necessary to achieve the expected impact of iCCM and CBNC. Key steps for improving utilization would be carrying out multifaceted demand generation activities, ensuring availability of HEWs in health posts and ensuring consistent supplies of essential commodities. The Women's Development Army has the potential to improving linkages between HEWs and communities, but this strategy needs to be strengthened to be effective.

Utilization of integrated community case management services in three regions in Ethiopia after two years of implementation.

BACKGROUND: The integrated community case management (iCCM) strategy has brought fully integrated treatment for sick children to the community in Ethiopia since 2010. OBJECTIVES: To describe patterns of use of iCCM services in 31 woredas (districts) in three regions of Ethiopia. METHODS: We analyzed all 60,452 encounters (58,341 [98.2%] for children 2-59 months of age and 2079 [1.8%] for children < 2 months of age) recorded in iCCM registration books from December 24, 2012 to January 15, 2013 in 622 randomly sampled health posts. RESULTS: Children 2-23 months constituted more than half (58.9%) of the total children treated, and about half of the registered infants < 2 months (1000/2079 [48.1%]) were not sick since some Health Extension Workers (HEWs) were recording well-infant visits. On average, sick children had 1.3 symptoms, more among children 2-59 months than among young infants (1.4 vs. 1.04, respectively). The main classifications for children 2-59 months were diarrhea with some or no dehydration (29.8%), pneumonia (20.7%), severe uncomplicated malnutrition (18.5%), malaria (11.2%), and other severe diseases (4.0%). More than half the sick children < 2 months (52.7%) had very severe disease. Treatment rates (per 1000 children per year) were low for all classifications: 11.9 for malaria (in malarious kebeles only), 20.3 for malnutrition, 21.2 for pneumonia, and 29.2 for diarrhea with wide regional variations, except for pneumonia. Nearly two-thirds of health posts (64%) treated ≤ 5 cases/month, but one treated 40. Health Extension Workers saw 60% more sick children 2-59 months in the third quarter of 2012 than in the third quarter of 2011. CONCLUSION: The use of iCCM services is low and increasing slowly, and the few busy health posts deserve further study. Recording healthy young infants in sick registers complicates tracking this vulnerable group.

Effect of performance review and clinical mentoring meetings (PRCMM) on recording of community case management by health extension workers in Ethiopia.

BACKGROUND: The Performance Review and Clinical Mentoring Meeting (PRCMM) is an approach to improve and sustain Health Extension Worker (HEW) skills and performance in integrated Community Case Management (iCCM). OBJECTIVE: To compare HEW performance in recording case management before and after they participated in PRCMM. METHODS: We conducted a historical cohort analysis of iCCM case records between September 2010 and December 2012 from 622 randomly selected health posts representing 31 intervention woredas (districts) of Amhara, Oromia and Southern Nations Nationalities and Peoples' Regions. We used longitudinal regression analysis comparing the trend in the consistency of the classification with the assessment, treatment and follow-up date as well as caseload in the periods before and after PRCMM, with 5511 and 7901 case records, respectively. RESULTS: Overall consistency improved after PRCMM for all common classifications as follows: pneumonia (54.1% [95% CI: 47.7%-60.5%] vs. 78.2% [73.9%-82.5%]), malaria (50.8% [42.9%-58.7%] vs. 78.9% [73.4%- 84.4%]), and diarrhea (33.7% [27.9%-39.5%] vs. 70.0% [64.7%-75.3%]). This improvement was consistently observed comparing the six months before and the six months after PRCMM in all the common classifications except for malaria where the improvement observed during the first three post-PRCMM months disappeared during the fifth and sixth months. Caseload increased significantly after PRCMM (6.6 [95% CI: 5.9-7.3] vs. 9.2 [8.5-9.9] cases/health post/month). CONCLUSION: PRCMM seemed to improve iCCM performance of HEWs and should be integrated within the PHC system and given about every six months, at least at first, to sustain improvement.

Utilization of Integrated Community Case Management Services in Three Regions in Ethiopia after Two Years of Implementation

Background: The integrated community case management (iCCM) strategy has brought fully integrated treatment for sick children to the community in Ethiopia since 2010. Objectives: To describe patterns of use of iCCM services in 31 woredas (districts) in three regions of Ethiopia. Methods: We analyzed all 60;452 encounters (58;341 [98.2] for children 2-59 months of age and 2079 [1.8] for children2 months of age) recorded in iCCM registration books from December 24; 2012 to January 15; 2013 in 622 randomly sampled health posts. Results: Children 2-23 months constituted more than half (58.9) of the total children treated; and about half of the registered infants 2 months (1000/2079 [48.1]) were not sick since some Health Extension Workers (HEWs) were recording well-infant visits. On average; sick children had 1.3 symptoms; more among children 2-59 months than among young infants (1.4 vs. 1.04; respectively). The main classifications for children 2-59 months were diarrhea with some or no dehydration (29.8); pneumonia (20.7); severe uncomplicated malnutrition (18.5); malaria (11.2); and other severe diseases (4.0). More than half the sick children 2 months (52.7) had very severe disease. Treatment rates (per 1000 children per year) were low for all classifications: 11.9 for malaria (in malarious kebeles only); 20.3 for malnutrition; 21.2 for pneumonia; and 29.2 for diarrhea with wide regional variations; except for pneumonia. Nearly two-thirds of health posts (64) treated 5 cases/month; but one treated 40. Health Extension Workers saw 60 more sick children 2-59 months in the third quarter of 2012 than in the third quarter of 2011. Conclusion: The use of iCCM services is low and increasing slowly; and the few busy health posts deserve further study. Recording healthy young infants in sick registers complicates tracking this vulnerable group