Theodros Getachew

Background: Ninety-nine percent of global maternity deaths occur in low-and-middle-income countries (LMICs), despite availability of high quality evidence-based guidelines for common causes of maternal mortality. An understanding of barriers and facilitators (BFs) to accessing and receiving evidence-based maternal care from the patients' perspective is lacking in the literature. We aimed to address this gap by assessing BFs to accessing and receiving evidence-based maternal care from the patients' perspective in two LMICs, Argentina and Ethiopia. Method: We employed a multi-center qualitative design including 58 interviews and eight focus groups with reproductive age women and their families in Argentina and Ethiopia. Interview and focus group data were analyzed using a framework approach to content analysis. Results: At the patient/community level, participants at both sites identified lack of knowledge as a barrier, and community belief in maternal care as a facilitator to women accessing and receiving care. Cultural beliefs, gender roles and decision making were identified as barriers and community funding to help with healthcare costs and education targeting husbands as facilitators, only in Ethiopia. At the provider level, mistreatment by providers was identified as a barrier in both sites, with mistrust of providers and preference for male providers barriers in Ethiopia only. Trust in providers was identified as a facilitator in Argentina, and local maternal health champions and providers from the local community facilitators in Ethiopia. Lack of coordination of care and transportation, and health care worker shortages, were identified as health system level barriers in both sites, and financial constraints noted only in Ethiopia. System level facilitators included patient education groups and use of social media in Argentina, and increased rural health centers and better organization of care, in Ethiopia. Conclusion: While the BFs identified by our participants are similar to those found in studies conducted with providers, our findings add to the literature by providing the unique perspectives of patients' and their families. In addition, variability in how specific BFs were experienced by patients/ families, highlights the importance of understanding context specific BF to allow for tailoring implementation strategies. Study registration: Open Science Framework https://osf.io/xmjf7 Registered June 4, 2022.

Background: Across the globe, rates of depression and anxiety have risen substantially since the COVID pandemic. Consequently, poor mental health is now a top health policy priority in many countries and more people than ever are seeking treatment. While the segment of people with poor mental health is large and growing, there is a dearth of data about their demographics and health needs and their use of and experience in the health system. Health systems require this information to effectively organize and provide services. Methods and findings: We investigated population prevalence of fair or poor mental health and compared health system experience and quality of care among adults with poor versus good mental health in 18 high-, middle-, and low-income countries using data from the People’s Voice Survey ( n = 32,419). Data were collected in 2022 and 2023 through a combination of nationally representative telephone, online, and in-person surveys. Prevalence of self-reported poor mental health ranged from 4.7% in Nigeria to 39.6% in China and was unrelated to national income per capita. More women than men reported poor mental health in most countries. Across all countries, people with poor mental health had worse self-rated overall health and more chronic illness. Between 0.9% (Lao PDR) and 52.4% (UK) of those with poor mental health had received mental healthcare in the past year. People with poor mental health reported lower patient activation, worse care quality, and lower confidence in the health system. A study limitation is that results are based on self-reported mental health rather than clinical diagnoses. Conclusions: People with poor mental health have markedly different health profiles and health system experience. These findings should prompt health systems to re-assess their services to better serve this growing patient group. Comparison of user experience and quality over time and across countries with similar health systems may assist in benchmarking performance.

Antenatal care (ANC) is crucial for maternal and newborn health. Although ANC coverage has improved globally, ANC quality remains suboptimal. This study assessed the quality of first ANC visits and their association with perinatal outcomes. We used data from the eCohort study that collected longitudinal data on ANC utilization and quality until the end of pregnancy in Ethiopia, Kenya, South Africa, and India. Perinatal outcomes of interest included fetal losses (miscarriages ≥13 weeks of gestation or stillbirths) and low birth weight (LBW) newborns. Good quality ANC at first visits was defined as receiving six essential care components: blood pressure measurement, blood and urine tests, ultrasound, iron and folic acid supplementation, and counseling on pregnancy danger signs. We conducted mixed-effect logistic regressions to assess associations between good quality ANC and perinatal outcomes, with sensitivity analyses where good quality ANC excluded ultrasound scans. Among 3,600 pregnant women followed until the end of pregnancy, 5.8% received all six components at their first visits (from 1.3% in India to 14.0% in Ethiopia), and 30.7% received five components (5.7% in India to 52.5% in Kenya). Between 3.7% of women in Ethiopia and 6.3% in India experienced a fetal loss. Between 8.5% of newborns in Ethiopia and 16.3% in India were born LBW. Good quality ANC at first visits was associated with a 32% to 59% lower risk of fetal loss (primary analysis: risk ratio (RR) 0.41, 95% confidence interval (CI) 0.10–0.72; sensitivity analysis: RR 0.68, 95% CI 0.44–0.92). No significant associations were observed between good quality ANC and LBW. This study identified important gaps in ANC quality and found that good quality ANC is associated with a lower fetal loss risk. Investments must be made to improve ANC quality and ensure the delivery of essential care in pregnancy.

Effective coverage measurement has emerged as a tool to help understand health system performance for the provision of high-quality health care. Using a cascade approach that combines data on demand- and supply-side steps, effective coverage measures highlight where gaps in the health system exist and how improvements might be made so that more people benefit from the potential of the health services available to them. In practice, however, there are challenges in making this work. This analysis paper aimed to highlight those challenges in calculating effective coverage in Ethiopia, using antenatal care as a test case, and propose a solution. In Ethiopia, government leaders are committed to taking a data-informed approach to improving health care quality. To support this, an effective coverage technical working group was formed of individuals with experience of effective coverage analysis in Ethiopia to share knowledge and create learning for a way forward. Through methods analysis of one common indicator, the effective coverage of antenatal care, four key challenges were identified by the group: (1) features of the data sources used, (2) the number of cascade steps included in the effective coverage calculations, (3) the data elements included within cascade steps and (4) the methods applied to generate composite indicators. Multiple small differences were observed to have an influence on the usability of effective coverage measures for decision-making. The group concluded that greater transparency in reporting effective coverage measures was urgently needed and proposed and discussed the use of a reporting checklist for this purpose.

Objective: Our objective was to assess the feasibility of using the routine health information system data source, District Health Information System (DHIS2) to measure the effective coverage of selected health service indicators in Ethiopia and to explore stakeholder perceptions of those measures. Design: We conducted a mixed-methods study. We mapped the availability of data elements in DHIS2 between July 2022 and June 2023 for five indicators (four or more antenatal care visits (ANC4+), skilled birth attendance, postnatal care, sick child care and child nutrition care). We defined effective coverage cascade steps for each indicator, assessed data quality and analysed data using STATA V.17. Finally, qualitative interviews were conducted with 15 key stakeholders, and the data were analysed thematically for reflections on the DHIS2 output. Setting: The data were captured from all public health facilities of 11 regions and 2 administrative cities in Ethiopia. Results: There was better availability of data elements for maternal healthcare than for child healthcare. It was possible to estimate the intervention-adjusted coverage of ANC4+ (16% nationally) and the process-quality-adjusted coverage of skilled birth attendance (19% nationally). Postnatal care, sick child care and child nutrition indicators lacked data across multiple cascade steps. The quality of data for effective coverage measurement differed by region. The key informants expressed concerns about the adequacy and appropriateness of DHIS2 data for this analysis. While all acknowledged its potential for decision-making, respondents emphasised the need for standardised methods and data sources to enhance comparability and acceptability of the findings. Conclusions: The findings underscore the need for system-level improvement of data availability and quality, and adoption of a standardised approach to calculating effective coverage using DHIS2. There was a concern that the findings may not be accepted by policymakers; however, the local level granularity made possible through DHIS2 was appreciated.

Ethiopia has prioritised high-impact interventions to reduce neonatal deaths, including antenatal corticosteroids (ACS) utilisation. However, effective ACS use has faced various challenges. We used multiple data sources to examine the current landscape of ACS use in Ethiopia and to elucidate barriers to effective ACS utilisation, including a review of national obstetric guidelines over the past decade, a review of literature, and a descriptive analysis of health facility data. National obstetric protocols recommend administering ACS in both hospitals and health centres. However, ACS remains substantially underused. The 2016 Ethiopian Emergency Obstetric and Newborn Care Assessment reported that only 5% of preterm infants were born to women who had received corticosteroids before delivery. At the health facility level, the 2021 Ethiopian Service Provision Assessment survey showed that only 22.1% of facilities providing antenatal care and delivery services had administered ACS in the past 3 months, and 44.7% of facilities had injectable corticosteroids in stock at the time of the survey. Notably, private clinics had both the lowest corticosteroid availability (16.9%) and utilisation rate (2.8%). We identified several barriers to effective ACS use, including healthcare service delivery organisation, gaps in healthcare providers’ knowledge and skills (particularly at the primary healthcare level and in private facilities), challenges in accurate gestational age assessment resulting from limited access to early ultrasound and late initiation of antenatal care, and insufficient corticosteroid availability. Increasing ACS uptake alone is unlikely to have the desired population benefits without considering health service delivery redesign and integration with other life-saving maternal and newborn health interventions.

Antenatal corticosteroids (ACS) use among pregnant women at risk of imminent preterm labour is one of the most effective interventions for improving neonatal survival. By accelerating fetal lung maturity, ACS can reduce the risks of respiratory distress syndrome by 30% and neonatal death by 20% [1]. The World Health Organization (WHO) and other professional medical […]

Background Antenatal care (ANC) is crucial for ensuring the health of pregnant women and their newborns. Although ANC coverage has improved globally, ANC quality remains suboptimal in some settings. Evidence on the association between ANC quality and perinatal outcomes in low-resource countries is still limited. Hence, this study assessed ANC quality and its relationship with fetal loss and low birth weight (LBW) newborns. Methods and findings We used data from the eCohort study that collected longitudinal data on ANC utilization and quality until the end of pregnancy across eight sites in Ethiopia, Kenya, South Africa, and India. Women were enrolled from public government-owned facilities only in India and South Africa and from both public and private facilities in Ethiopia and Kenya. Primary outcomes included fetal loss (≥13 weeks of gestation) and LBW. Good quality ANC was defined as receiving six essential care components during the first ANC visit: blood pressure measurement, blood and urine tests, ultrasound, iron and folic acid supplementation, and counseling on pregnancy danger signs. We conducted mixed-effect logistic regressions to assess the association between good quality ANC and perinatal outcomes, with a sensitivity analysis where good quality ANC excluded ultrasound scans. Among 3,597 pregnant women followed until the end of pregnancy, only 5.8% received all six essential care components during their first ANC visit (ranging from 1.4% in India to 14.0% in Ethiopia) and 30.7% received five care components (excluding ultrasounds) ranging from 5.7% in India to 52.5% in Kenya. Fetal loss prevalence was 3.7% in Ethiopia, 3.8% in Kenya, 4.0% in South Africa, and 6.0% in India. India and South Africa had higher rates of LBW newborns (among neonates who were alive at the time of the survey): 16.3% and 13.1%, respectively, compared to 8.6% in Ethiopia and 8.5% in Kenya. Multiple pregnancies were rarely detected at the first ANC visit. Good quality ANC was associated with a 22% to 58% lower risk of fetal loss (RR 0.78, 95% CI 0.61 – 0.95 to RR 0.42, 95% CI 0.10 – 0.73). No statistically significant associations were observed between good quality ANC and LBW. Conclusions This study identified important gaps in ANC quality and found that receiving essential ANC services was associated with a lower risk of fetal loss. With increasing global ANC coverage, future research should continue assessing quality, and programs should prioritize quality improvement, ensuring the delivery of good clinical practice and proven evidence-based interventions in pregnancy. Why was this study done? ANC utilization has significantly increased in low-resource settings; however, the quality of care received remains insufficient. Most prior research investigating the associations between ANC and perinatal outcomes has focused on ANC utilization or the number of visits. While the global dialogue has gradually shifted to ANC quality rather than merely ANC utilization, limited evidence has explored the association between ANC quality and critical perinatal outcomes, including fetal loss and LBW newborns. What did the researchers do and find? We used data from a longitudinal study that collected information on the utilization and quality of ANC throughout pregnancy and assessed the care received and its relationship with fetal and neonatal outcomes. Our study found that ANC quality was overall poor. Only 6% of pregnant women received all six care components (blood pressure measurement, blood and urine tests, ultrasound examination, iron and folic acid given or prescribed, and counseling on pregnancy danger signs) at their first ANC visits and only 31% received five care components (excluding ultrasounds). Good quality ANC was significantly associated with a lower risk of fetal loss (including late miscarriage and stillbirth), while no significant association was found between the receipt of good quality ANC and LBW newborns. What do these findings mean? Poor-quality antenatal care is not only inefficient but can also be harmful. This issue is particularly concerning as increasing numbers of women in low-resource settings seek ANC services. Efforts at the national level should ensure the delivery of good clinical practice and essential care components for high quality ANC to improve perinatal outcomes.

Objectives To assess the geographical equity in Ethiopian infants’ exclusive breastfeeding at 5 months and dietary diversity at 12 months and whether social factors explained the spatial inequities. Design Secondary analysis of a birth cohort study. Setting Analysis of data from the Ethiopian Performance Monitoring for Action panel study conducted from July 2020 to August 2021 in five regions (ie, Oromia, Amhara, Afar and Southern Nations, Nationalities and Peoples regions and the Addis Ababa City administration). We analysed geographical autocorrelation to assess geographical variations in exclusive breastfeeding and dietary diversity. Areas with higher and lower coverage of appropriate infant feeding outcomes were analysed using hotspot analyses. We performed geographically weighted regression to investigate whether sociodemographic factors explained the geographical feeding differences. Participants 1850 infants were prospectively followed from birth to 12 months. Outcome measures Exclusive breastfeeding at 5 months and minimum-level dietary diversity at 12 months. Results Sixty-nine percent (95% CI 67 to 71) of infants were exclusively breastfed at 5 months, while at 12 months, only 16% (95% CI 13 to 19) had complementary feeding from five or more food groups. There were geographical variations in the coverage of exclusive breastfeeding and minimum dietary diversity. Higher proportions of infants were exclusively breastfed at 5 months in northern areas, and more 12-month-old infants in central parts of the country had complementary feeding from at least five food groups. Sociodemographic factors explained a quarter of the geographical variation in dietary diversity. Conclusion Most Ethiopian infants were exclusively breastfed, which was in line with global recommendations but with some geographical differences. There was prominent geographical variation in dietary diversity, partly explained by social factors, but overall, very few 12-month-old infants were fed from at least five food groups. This low dietary quality could impair Ethiopian children’s physical growth, development and health.

Building a culture of quality is vital for sustaining high-quality healthcare, emphasising shared values and continuous improvement. The Quality Equity and Dignity (QED) network was a global initiative working toward this objective, focusing on maternal and newborn health. This paper aims to describe how QED influenced five identified attributes of quality culture in Ethiopia: leadership, people-centered interventions, collaboration, rewards, and ownership towards building and sustaining a culture of quality in healthcare establishments. This qualitative study, conducted at two points six months apart, incorporated data from key informant interviews, observations, and document reviews. It included 18 national and 22 sub-national key informant interviews, seven facility observations, and one technical working group meeting observation. Data analysis was performed using NVivo 12 software, focusing on identified thematic areas related to quality culture. Leadership was crucial for building a quality culture in Ethiopia, and the QED network strengthened government leadership structures, although leadership capacity and staff turnover were challenges. QED enhanced people-centered care and data tracking, but the added data focus burdened healthcare workers. Opportunities for collaboration and shared learning were facilitated, although not accessible to all actors. Motivation and rewards encouraged good performance, but addressing intrinsic behavioral change remained a challenge. Achieving high-quality healthcare involves more than tools and infrastructure; it requires a cultural shift with behavior change consistently demonstrated at various levels. The QED network faced challenges in building a culture of quality but serves as an exemplary initiative for other networks to learn from.