Assefa Seme

Background: Unsafe abortion is a significant global health concern, contributing to high rates of maternal mortality, particularly in developing countries. Women in pastoralist communities face unique challenges to access comprehensive abortion care (CAC) due to sociocultural, economic, and geographical barriers. This study explores the lived experiences of women in their journey to utilize CAC services in pastoralist communities of the Oromia region, Ethiopia. Methods: A phenomenological study was conducted in pastoralist communities of the Oromia region, including the Borana and Guji zones. A total of nine women were interviewed in-depth for their lived experiences in their journey to access the CAC service. All interviews were audio-recorded, transcribed verbatim, translated to English, and coded using Open Code version 4.03 software. Both inductive and deductive thematic analysis were employed to analyze the data. The lived experiences of women in their journey to access CAC services were analyzed under three categories: ‘before’, ‘during’, and ‘after’ utilizing the CAC service. Results: Before receiving CAC service, women faced emotional instability, fear, decision-making difficulties, and barriers such as transportation challenges, stigma, and lack of family support. During the service, women reported mixed experiences with healthcare providers, with some receiving supportive care while others reported disrespect and a lack of privacy. Following receiving CAC service, experiences included both relief and satisfaction for some, while others expressed regret and guilt due to cultural and religious beliefs surrounding abortion. Conclusion: The study reveals the complex experiences of women in their journey of accessing CAC services in pastoralist communities, worsened by socio-cultural norms, economic hardship, and limited healthcare infrastructure. Addressing the barriers identified, particularly those related to stigma, provider attitudes, and healthcare accessibility, is essential for improving CAC service delivery in these underserved regions.

Women´s emotional fertility intentions to conceive are an integral part of Reproductive Health (RH) right which can also be considered as decision-mak

Women´s index pregnancy emotional fertility intention was measured by asking the pregnant women how they would felt when they learned about their index pregnancy. Emotional health and couples´ communication are key during pregnancy and child birth with simultaneous minimization of reproductive coercion. Emotional fertility intention is critical for healthy and spaced pregnancies, as well as for better maternal and newborns outcomes. Besides, intentions to conceive and emotional fertility intention on pregnancy are the integral parts of women reproductive health (RH) right and can be considered as women decision-making ability over their fertility. Moreover, in low and middle-income countries including Ethiopia where the sole male´s dominance is culturally accepted and socially constructed, males take the lead in each decision making process including household-level decision, determining the family´s fertility and reproductive health service use. This dominance interferes with women fertility intention and their health status including their emotional feeling towards conception. In such a scenario, women are less likely for their say to be heard. Hence, this study aimed to determine pregnant women index pregnancy emotional fertility intention and to identify the associated covariates contributing to it in Ethiopia. This is a very critical step to generate and make actionable evidence available for the health ministry and relevant partners working on reproductive and women´s psycho-social health. This evidence could serve as an action point to empower women regarding their reproductive health right and the control over their fertility. Nationally representative cross sectional baseline data from the Ethiopian performance monitoring for action (Ethiopian PMA) cohort one survey, which enrolled and collected data from currently pregnant and 6 weeks postpartum women were used for this study. This study collected real time data on various sexual, reproductive, maternal and new born nationwide priority indicators using customized Open Data Kit Mobile application. These data were collected using standard pretested questionnaire prepared in English and the three local languages (Amharic, Afan Oromo and Tigrigna) by well experienced resident enumerators. This study was restricted to 2,236 pregnant women at the enrollment. Frequencies were computed to characterize pregnant women, and chi-square statistics was used to assess cell sample size adequacy. Multinomial logistics regression statistical modeling was fitted to identify correlates affecting index pregnancy women´s emotional fertility intention. Results were presented in the form of percentages and odds ratio with 95% Confidence Intervals. Candidate variables were selected using a p-value of 0.25. Statistical significance was declared at p-value of 0.05. The overall proportion of index pregnancy emotional fertility intention of being happy was found to be 67.81%: (95%CI: 65.38, 70.13). The proportion of pregnant women who felt very unhappy was 8% (95%CI: 6.64, 9.5) while 8.45% (95%CI: 7.13, 10.0) and 15.79% (95%CI: 14.01, 17.76) of the pregnant women reported that they felt a sort of unhappy and mixed feelings respectively. Besides, older women, those from the well to do households, those who wanted to have another child were found to have (AOR 95%CI: 2.82 (1.30, 6.13), (AOR 95%CI: 2.05 (1.04, 4.04) and (AOR 95%CI: 2.96 (1.95, 4.52) times increased likelihood of index pregnancy emotional fertility intention of being happy when they have learned about their index pregnancy. The likelihood of index pregnancy emotional fertility intention was found to be AOR 95%CI: 0.34 (0.19, 0.62), (AOR 95%CI: 0.50 (0.32, 0.78), (AOR 95%CI: 0.26 (0.17, 0.40) and (AOR 95%CI: 0.38 (0.25, 0.58) lower among women with high birth order, those who intended to have no more child, among residents of Oromiya and among the residents of the former Southern nations, nationalities and peoples regions. Moreover, the likelihood of index pregnancy women emotional fertility intention of being in a mixed feelings was found to be (AOR 95%CI: 0.62 (0.41, 0.95), (AOR 95%CI: 0.30 (0.13, 0.67) and (AOR 95%CI: 0.33 (0.14, 0.77) among women who attended primary education, those whose desired birth attendant was health professional and family member respectively. The finding that 2/3 of the pregnant women felt happier calls us up to work on intended and spaced pregnancies by ensuring women reproductive and economic empowerment. Region specific and age sensitive activities and efforts that promote intended pregnancy, empower women economically; increase women´s enrollment to secondary education or above and assisting them in identifying their desired birth attendant as part of birth preparedness and complication readiness are hoped to enhance pregnant women index pregnancy emotional fertility intentions. Empowering women economically and improving women educational enrollment were found very critical to address women emotional fertility intention. Installing inter pregnancy preconception care packages in the health care system and postpartum contraceptive counseling’s and provision were found to be the main implications of the study´s findings.

Background: Perceived paternal emotional fertility intentions were measured by asking pregnant women how their husbands felt when they have learnt about the index pregnancy. Paternal emotion during pregnancy and childbirth is imperative for better maternal and newborn health outcomes, though policy and strategic framework has been lacking in Ethiopia. Therefore, this study aimed to explore perceived paternal emotional fertility intentions of their husbands and/or their male partners and examine its correlates among a panel of pregnant women in Ethiopia. Methods: Nationally representative data from cohort one baseline cross-sectional survey were used. A total of 2,115 pregnant women from a total of 217 enumeration areas were included in this further analysis. Frequencies were computed to describe pregnant women. Multinomial logistics regression statistical modeling was fitted to identify correlates of perceived paternal emotional fertility intentions. Results were presented in the form of percentages and odds ratio with 95% Confidence Intervals. Statistical significance was declared at a p-value of 0.05. Result: The proportion of perceived paternal emotional fertility intentions of being a sort of happy and very happy were found to be (35.40%; 95%CI: 33.00%, 37.87%) and (49.03%; 95%CI: 46.48%, 51.6%) respectively. The likelihood of perceived paternal emotional fertility intentions of being very happy was (AOR: 95%CI: 5.06: (1.73, 14.85) and (AOR: 95%CI: 2.65: (1.67, 4.20) times higher among older pregnant women and those who intended having another child respectively. On the contrary, those with higher birth order, who wanted no more another child, those living as a partner and; those residing in Addis Ababa and SNNPR had (AOR: 95%CI: 0.25: (0.15, 0.40), AOR: 95%CI: 0.14: (0.07, 0.27); (AOR: 95%CI: 0.54: (0.33, 0.90), (AOR: 95%CI: 0.34: (0.17, 0.67), (AOR: 95%CI: 0.27: (0.14, 0.53) and AOR: 95%CI: 0.25: (0.15, 0.40) times lower likelihood of perceived paternal emotional fertility intention of being very happy about the index pregnancy respectively. The likelihood of perceived paternal emotional fertility intentions of being a sort of happy was found to be (AOR: 95%CI: 1.93 (1.21, 3.10) times higher among those wanting to have another child. This likelihood was found to be (AOR: 95%CI: 0.62 (0.43, 0.89), (AOR: 95%CI: 0.43 (0.22, 0.85) and (AOR: 96%CI: 0.45 (0.28, 0.74) times lower among those whose desired place of delivery was health facility, with higher birth order and residents of Oromiya region respectively. Conclusion: Half of the pregnant women perceived that their husband felt very happy with calls up on a region specific age sensitive interventions in improving couples communication, and discussion on the spacing and timing of pregnancies as well as to work on improving childbirth preparedness and complication readiness. The ministry and relevant partners need to work strategically on male’s involvement in fertility desire along with emotional care and support. Women with future fertility intention, lower birth orders and those who have not legally married need to be targeted. Installing inter pregnancy preconception care package; improving counseling and provision of postpartum contraceptives; increasing men fertility knowledge and their emotional readiness; and lifestyle adjustment before pregnancy to improve psycho-social health during the perinatal period and paternal emotional fertility intentions are imperative.

Current intimate partner violence (IPV) in Ethiopia is considerably high. This study aimed at determining the prevalence of IPV among a panel of pregnant women during their index pregnancy and identify its correlates using Performance Monitoring for action (PMA) cohort 2 baseline data. Documenting the magnitude of IPV thus far during the index pregnancy and identifying factors affecting it contributes its share for the ministry and relevant developmental partners in tracking progress towards eliminating all forms of violence against women and girls by 2030. We conducted a further analysis of national level follow up secondary data sets from Performance Monitoring for action Ethiopian (E_PMA). This study used PMA cohort two baseline data which enrolled pregnant and recently postpartum women and collected real time data on various sexual, reproductive, maternal and new born nationwide priority indicators using customized Open Data Kit Mobile application. These data were collected using standard pretested questionnaire prepared in three local languages (Amharic, Afan Oromo and Tigrigna) by well experienced resident enumerators. This study was restricted to 1,796 pregnant women at the enrollment. Frequency was computed to describe the study participant’s characteristics, and chi-square statistics was used to assess cell sample size adequacy. Multilevel binary logistics regression model building process was employed to identify correlates of IPV. Results were presented in the form percentages and odds ratio with 95% Confidence Intervals. Candidate variables were selected using p-value of 0.25. Statistical significance was declared at p-value of 0.05. One in six; 16.7% (14.81%, 18.76%) pregnant women have reported experiencing at least one form of physical and/or sexual IPV thus far in their index pregnancy. The prevalence of encountering at least one form of sexual violence was 12.53% (10.91%, 14.35%) while 7% (5.5%, 8.3%) of them experienced at least one form physical intimate partner violence thus far during their index pregnancy. Women perceived risk about contraceptive use ((AOR: 95% CI: 1.66 (1.10, 2.47)), higher birth order ((AOR: 95% CI: 1.88 (1.05, 3.34)), unhappy emotional fertility intention when learned their index pregnancy ((AOR: 95% CI: 1.7 (1.02, 2.84)) and a family size of 4 to 5 ((AOR: 95% CI: 1.87 (1.11. 3.14)) were the fixed effects factors found to increase the odds of IPV significantly and positively. On the contrary, being in the third trimester of gestation at enrollment was another fixed effect variable which contributed for the 44% lower odds ((AOR: 95% CI: 0.56 (0.34, 0.92)) of experiencing IPV thus far in their index pregnancy. The overall burden of IPV reported was high; with nearly double the percentage of women experiencing sexual violence during the index pregnancy compared to physical IPV. More work needs to be done to achieve zero tolerance against any form of violence among women and girls in general and among pregnant women in particular. Efforts targeted in improving women perception on issue related with their contraceptive use, counseling women on how to prevent IPV during their antenatal care (ANC) visit along with advising the use of inter pregnancy contraception and empowering them to control on their fertility are hoped to mitigate such considerably higher odds of IPV among pregnant women. Further programs and intervention on awareness creation towards the misconception that women held about contraceptive use would contribute much. These activities and efforts need to target younger women. The implication of the findings calls key actors and the Federal Democratic Republic of Ethiopia Health Minster to design and implement programs on women emotional fertility readiness and empowering them to control over their fertility through diversified contraceptive provision which is critical in combating the reported substantial IPV experience during pregnancy. Creating institutional capacity in the health system through strengthening and expanding one stop centers to provide medical treatment, care, and psychosocial support for victims and survivors could play a pivotal role. In addition, installing rapid referral system and linkage to the legal system could play a vital role. Moreover, working on early marriage and counseling on childbirth; and spaced pregnancy for those young couples is imperative. Further implication of this study was installing contraceptive and violence related preconception care packages in the health system is very critical in the combat against IPV and any form of gender based violence.

Introduction In this era of SDG countries relatively achieving maternal and newborn health geographic coverage are moving to a new paradigm called completion of maternal and new born care continuum (MN- CoC). Measuring the influence of significant others: partner/or husband and community engagement are considered as pivotal and one of the pillar strategies to achieve of completion of MN-CoC. Unfortunately, there is a lack of policy framework for partner and/or husband involvement in pregnancy, childbirth and postnatal care and when exists there is a gap in policy and practice in developing countries context. Articulating and endorsing such policy is likely to promote husband and/or partner encouragement and support during at the enrollment to maternal and newborn care continuum (MN-CoC). Hence, quantifying the level of MN-CoC partner dynamics on antenatal care visit and/or discussion about where to deliver the index child at and identifying its correlates among a panel of six weeks postpartum women provides evidence for the policy articulation endeavor by the Federal Health Ministry of the Federal Democratic Republic of Ethiopian and developmental partners working on reproductive and maternal and newborn health care. Methods Community based nationally representative longitudinal data collected from a panel of pregnant and six weeks postpartum women were further analyzed. A total of 2,207 six weeks postpartum women who were married and/or living a partner were included in this analysis which was adequate to yield an unbiased estimates for MN-CoC partner dynamics. Multinomial logistics regression was run to identify correlates of partner Dynamics. Results were presented in the form percentages and odds ratio with 95% Confidence Intervals. Statistical significance was declared at p-value of 0.05. Results The proportion of partner and/or husband dynamics on MN-CoC of among six weeks postpartum women who reported that their partner and/or husband encouraged them to go to clinic for ANC and discussed with them about place of delivery for the index child was nearly 2/3 (64.67%; 62.21%, 67.04%).Besides, nearly one in 5 of them reported that their husband and/or partner did not encourage (18.2%; 16.64%, 20.33) and encouraged either of the first two MN-CoC two domains (17.08%, 15.25%, 19.10%). The region women residing, being in a polygamy marriage, contraceptive ever use history, attainment secondary/higher education and index child delivery place were found to contribute for the variation in MN-CoC partner dynamics. The finding calls up on regionally sensitive activities and efforts with public-private partnership in service provision and targeting women with polygamy which in turn empower women to control over their fertility through increasing higher education enrollment, and diversifying access to contraceptive commodities are hoped to improve MN-CoC partner dynamics thereby enabling women in completing maternal and new born care continuum. Such endeavors and interventions are hoped to facilitate the ministry and other developmental partners’ comprehensive efforts to address the MN-CoC partner and/or partner dynamics in terms of policy articulation, advocacy, implementation, evaluation and revising it to fit its purpose and attain the desired targets. Purpose of Conducting the Study In every community, pregnancy and childbirth are expected to be joyful and positive experiences for the mother, the newborn and as well as for the families, however, neonatal, infant and maternal mortality is unacceptably high in low and middle income countries including Ethiopia. It is experienced not as the joyful event it should be, but as a dangerous and frightening time in their lives. In order to address such considerable problem, in the SDG era the focus of policy articulation, program concentration and research undertaking in maternal and newborn health care has shown a paradigm shift of measuring the completion of maternal, newborn care continuum (MN-CoC) by streamlining resources that were invested independently on each care continuum domains. Besides, WHO recommended completion of the three main domains of the maternal and newborn care continuum as pivotal strategy to improved maternal and new born health outcomes. Accordingly, partner encouragement, support and accompany during antenatal care, childbirth and postnatal care is one of the proposed strategy for pregnant women to be enrolled, retained and complete the maternal and new born care continuum including in sought care in the extended six postpartum period in particular and the inter pregnancy period in general. This is based on the evidence pool on the influence of significant others surrounding the women, notably; the community where they are residing and their partner and/or husband on health service use is considerably high. Determining the level of partner dynamics on the MN-CoC domains and identify its correlates is critical to track the progress of the proposed strategy. Nationally representative data collected from a panel of pregnant and six weeks the six post-partum women were used. Added Value of the Study Nearly 1 in 5 panel of women by their six week postpartum reported that they did not received any encouragement on the two first domains MN-CoC during their index pregnancy. Regional variation was observed in the level of partner dynamics at maternal and newborn care continuum enrollment domains (MN- CoC) and the variation was also explained by contraceptive ever use history as well. Women in polygamy marriage were less encouraged to go to clinic for ANC and lower opportunity to discuss where to deliver the index child with their partner and/or husband. . Implication of the Study The Federal Democratic Republic of Ethiopian Health Ministry and developmental partners need to articulate and endorse male involvement policy with region specific integrated public private strategies which improve women autonomy to control over their fertility and women higher education enrollment with a focus on women with polygamy so as to increase partner dynamics on MN-CoC. Partner encouragement on the first two domains of is key to enroll and retain pregnant women within the MN- CoC. There is a need to strengthen postpartum family planning counseling and diversifying the provision. Similarly women in polygamy needs attention. The need for installing preconception care in the health system to be provided in and around pregnancy and child birth; particularly the inter pregnancy preconception care package.

Background: Emotional health and couples communication are key during pregnancy and childbirth with simultaneous minimization of reproductive coercion which should be maintained in the postpartum period to maintain inter pregnancy period healthy and make the next pregnancy planned and successful. The postpartum period is key in the newborn development milestone and maintain maternal health. Women intentions to conceive are an integral part of Reproductive Health (RH) right and can be consider as decision making on their fertility control. However, in low and middle income countries including Ethiopia where male dominance is culturally constructed and socially acceptable, males take the lead in every decision making process for the family ranging from house level decision including to determine number of children that the family and new born RH rights and RH health service use. In such a scenario women may say not have heard likely hence, this study aimed at determining the level of women emotional fertility readiness and its correlates so as to avail actionable evidence for the ministry and partners working Reproductive and women health so as to be used as an action point to empower women on their reproductive health right to control their fertility. Methods: Nationally representative 2-year cohort data collected from pregnant women in four rounds were used. Frequency was computed to describe the study participant’s characteristics. Generalized ordered logistics regression was employed to identify correlates of the hierarchical variation in one year postpartum women fertility intention if they became pregnant. Results were presented in the form percentages and odds ratio with 95% Confidence Intervals. Candidate variables were selected using p-value of0.25. Statistical significance was declared at p-value of 0.05. Results: One in 20, (4.63% (3.60%, 5.94%)) postpartum women have reported that they felt very happy. Nearly two third 64.87% (62.20%, 67.45%) of one year postpartum women have reported that they very or a sort of unhappy by one year post-partum when asked what do they feel if they became pregnant. Nearly one in 6, (17.12% (15.15%, 19.29%)) women reported mixed feeling in the same period. Women who reported they have ever used contraceptive and those who reported that they have started contraceptive use one year postpartum had a proportional cumulative logit of 0.66 (0.44, 0.97) and 0.43 (0.29, 0.63) respectively across the higher level categories of one year postpartum women emotional fertility intention compared with their counter parts. The likelihood of one year postpartum emotional fertility intention among women with higher birth order and those who do not wanted additional child was found lower and asymmetrically across the higher level categories. Conclusion: Nearly 2/3 of one year post-partum women have reported very unhappy or a sort of unhappy if they became pregnant while one in 6 and one in five felt mixed feeling if they became pregnant one year postpartum respectively calls up on intended and spaced pregnancies by ensuring women reproductive decision making to control over their fertility. Activities and efforts that promote intended and spaced pregnancies; and diversifying access to contraceptive methods are likely to improve the level of one year postpartum women emotional fertility intention. Activities that enable women to decide their contraceptive use along with patient centered contraceptive use counseling as well. The implication the findings is that awareness creation on preconception and availing the service is also hoped to address the varying level of one year postpartum emotional fertility intention.

Background: Facility readiness is an important prerequisite for providing safe, effective childbirth care. This study assesses the readiness of health facilities in Ethiopia to provide childbirth services, describes variations in geographic access to service-ready facilities, and evaluates how facility readiness relates to childbirth service usage with a lens on equity. Methods: The study used cross-sectional data from a nationally representative sample of households in Ethiopia linked with data from health facilities serving the same areas. We explored variation in childbirth service readiness across facilities and classified facilities as “service-ready” if they had a readiness score of 0.75 or higher on a 0-1 scale. We used logistic regression modeling to examine the odds of residing within 10 kilometers of a service-ready facility by socioeconomic and geographic characteristics, and the odds of a facility delivery given the readiness of nearby facilities. Results: Childbirth service readiness was generally high for hospitals (median score: 0.92) with minimal variation (interquartile range, IQR: 0.88 to 0.96). Health centers and clinics displayed lower and more variable readiness (median: 0.75, IQR: 0.66 to 0.84). In both crude and adjusted regression analyses, odds of residing within 10 kilometers of a service-ready facility were significantly greater for women with higher education levels, greater wealth, and urban residence. We found the adjusted odds of using facility childbirth services were 1.23 (95% CI: 1.03, 1.48) times greater for each 0.10-unit increase in the readiness level of nearby facilities. Conclusions: Access to childbirth care is not equal for Ethiopian women. Those living in rural areas and the poor must travel farther to reach facility childbirth services, and the nearest facilities serving these women were less prepared to provide quality care. This may contribute to lower service utilization by such disadvantaged groups of women.

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

The Global Gag Rule (GGR) makes non‐U.S. nongovernmental organizations (NGOs) ineligible for U.S. Government global health funding if they provide, refer, or promote access to abortion. This study quantitatively examines the impacts of the GGR on family planning service provision in Ethiopia. Using a panel of health facilities (2017–2020), we conduct a pre–post analysis to investigate the overall changes in family planning service provision before and after the policy came into effect in Ethiopia. Our pre–post analyses revealed post‐GGR reductions in the proportions of facilities reporting family planning provision through community health volunteers (−5.6, 95% CI [−10.2, −1.0]), mobile outreach visits (−13.1, 95% CI [−17.8, −8.4]), and family planning and postabortion care service integration (−4.8, 95% CI: [−9.1, −0.5]), as well as a 6.1 percentage points increase in contraceptive stock‐outs over the past three months (95% CI [−0.6, 12.8]). We further investigate the impacts of the GGR on facilities exposed to noncompliant organizations that did not sign the policy and lost U.S. funding. We do not find any significant additional impacts on facilities in regions more exposed to noncompliant organizations. Overall, while the GGR was slow to fully impact NGOs in Ethiopia, it ultimately resulted in negative impacts on family planning service provision.