IntroductionDespite the international emphasis in the last few years on the need to address the unmet health needs of pregnant women and children, progress in reducing maternal mortality has been slow. This is particularly worrying in sub-Saharan Africa where over 162,000 women still die each year during pregnancy and childbirth, most of them because of the lack of access to skilled delivery attendance and emergency care. With a maternal mortality ratio of 673 per 100,000 live births and 19,000 maternal deaths annually, Ethiopia is a major contributor to the worldwide death toll of mothers. While some studies have looked at different risk factors for antenatal care (ANC) and delivery service utilisation in the country, information coming from community-based studies related to the Health Extension Programme (HEP) in rural areas is limited. This study aims to determine the prevalence of maternal health care utilisation and explore its determinants among rural women aged 15–49 years in Tigray, Ethiopia.MethodsThe study was a community-based cross-sectional survey using a structured questionnaire. A cluster sampling technique was used to select women who had given birth at least once in the five years prior to the survey period. Univariable and multivariable logistic regression analyses were carried out to elicit the impact of each factor on ANC and institutional delivery service utilisation.ResultsThe response rate was 99% (n=1113). The mean age of the participants was 30.4 years. The proportion of women who received ANC for their recent births was 54%; only 46 (4.1%) of women gave birth at a health facility. Factors associated with ANC utilisation were marital status, education, proximity of health facility to the village, and husband’s occupation, while use of institutional delivery was mainly associated with parity, education, having received ANC advice, a history of difficult/prolonged labour, and husbands’ occupation.ConclusionsA relatively acceptable utilisation of ANC services but extremely low institutional delivery was observed. Classical socio-demographic factors were associated with both ANC and institutional delivery attendance. ANC advice can contribute to increase institutional delivery use. Different aspects of HEP need to be strengthened to improve maternal health in Tigray.

BackgroundIn 2004, Ethiopia switched its first-line treatment of uncomplicated Plasmodium falciparum malaria from sulphadoxine-pyrimethamine to a fixed artemisinin-based combination therapy (ACT), artemether-lumefantrine (AL). Patient adherence to AL regimen is a major determining factor to achieve the desired therapeutic outcome. The aim of this study was to measure patient adherence levels to the six-dose AL regimen for the treatment of uncomplicated P. falciparum malaria and to identify its determinant factors in rural areas of the Tigray region, EthiopiaMethodsThe study was conducted under routine health service delivery at health posts level. Patients/caregivers were not informed about their home visit and were traced on the day after they finished the AL regimen. By combining the response to a structured questionnaire and the tablet count from the blister, adherence level was classified into three categories: definitely non-adherent, probably non-adherent and probably adherent. Reasons for being definitely non-adherent were also assessed. For the purpose of examine risk factors, definitely non-adherent and probably non-adherent was merged into a non-adherent group. Variables found significantly associated (p < 0.05) with the adherence level on the univariate analysis were fitted into a multivariate logistic regression model.ResultsOut of the total initially enrolled 180 patients, 86.1% completed the follow-up. Out of these, 38.7% were classified as probably adherent, 34.8% as probably non-adherent, and 26.5% were definitely non-adherent. The most common reasons that definitely non-adherents gave for not taking the full dose were "too many tablets" (37.3%) and to "felt better before finished the treatment course" (25.5%). The adherence of the patients was associated with the ownership of a radio (adjusted odd ratio, AOR: 3.8; 95% CI: 1.66-8.75), the belief that malaria can be treated traditionally (AOR: 0.09; 95% CI: 0.01-0.78) and a delay of more than one day in seeking treatment after the onset of fever (AOR: 5.39; 95% CI: 1.83-15.88).ConclusionThe very low adherence to AL found in this study raises serious concerns for the malaria control in the region. The implementation of a monitoring adherence system is essential to ensure long-term treatment efficacy.

BackgroundEthiopia is the second most populous country in Africa with a total fertility rate (TFR) of 4.8 children per a woman and contraceptive prevalence rate (CPR) of 29 %. The overall prevalence of modern family planning in a pastoralist community, like Afar region, is low (9.1 %). This study aimed to assess family planning utilization and associated factors among married women of Afar region, Eastern Ethiopia.MethodsA community-based cross-sectional study was conducted from January 10-28, 2013 among 602 women. Multistage sampling technique was used to select the study participants. Descriptive and multiple variable logistic regression analyses were done to isolate independent predictors on utilization of family planning using SPSS 20.ResultsThe overall prevalence of family planning utilization in Afar region was 8.5 % (6.2–10.7). Majority of the women (92.2 %) had used injectable. The most common reasons mentioned in the non-use of family planning methods were religion-related (85.3 %), desire to have more children (75.3 %), and husband's objection (70.1 %). Women who had a positive attitude towards family planning utilization (AOR = 4.7, 95 % CI: 2.1, 10.3), owning radio (AOR = 1.8, 95 % CI: 1.02, 4.18), and literate (AOR = 4.4, 95 % CI: 1.80, 11.08) were more likely to use family planning methods as compared to their counterparts. The increase of monthly income was also associated with the likelihood of family planning methods utilization. The odds of using family planning methods were higher among those with monthly income of $27–$55.5 (AOR = 2. 0, 95 % CI: 1.9, 4.7) and > $55 (AOR = 4. 6, 95 % CI: 1.23–17.19) as compared to women with the lowest category of monthly income ($27 and less).ConclusionThe low coverage of family planning in the region could be due to the influence of husband, religious and clan leader. Attitude of women towards family planning methods, possession of radio, monthly income, and educational status could influence family planning utilization.

BackgroundSince 2004, the government of Ethiopia has made a bold decision to strengthen and expand its primary health care system by launching the Health Extension Program (HEP). While the scaling up of the HEP is necessary to achieve the aim of universal access to primary health care, close attention should be paid to the performance of the program. Using a data envelopment analysis this study aimed at (i) to estimate the technical efficiency of a sample of health posts in rural Tigray, ii) to identify those factors which might be explaining the efficiency results.MethodsEfficiency was measured using a data envelopment analysis model. A Tobit model was performed to identify factors associated with efficiency. Seven rural districts (out of 35) were purposely chosen. Input/output information was collected from the database of the Tigray Health Bureau during July 2007-June 2008. Information was also collected on environmental factors that might influence the efficiency outcomes through a structured questionnaire from the correspondent district health officers.ResultsAnalysis was based on data from 60 health posts. The mean scores for technical and scale efficiency were 0.57 (SD = 0.32) and 0.95 (SD = 0.11) respectively. Out of the 60 health posts, 15 (25.0%) were found to be technically efficient constituting the best practice frontier. Thirty eight (63.3%) were operating at their most productive scale size. In the regression analysis, none of the variables was significantly associated with the efficiency outcome.ConclusionThere is a need to review the management of the health information system in the region. The findings have also revealed that only a quarter of the health posts are working efficiently and pointed the need for improvement. A closer monitoring of the health extension programme is required in order to achieve the best possible performance.

ObjectiveTo assess the knowledge, attitude and practice (KAP) regarding malaria and their determinants in a rural population of northern Ethiopia.MethodsThe study was conducted in the district of Samre Saharti, Tigray, northern Ethiopia. A structured questionnaire collecting socio-demographic and malaria-related KAP information was administered to the mothers from a representative sample of households.ResultsA total of 1652 questionnaires were available for analysis. Most of the respondents (92.7%) were able to mention at least one symptom of malaria. Mosquito as a cause of malaria was recognized by nearly half of the respondents (48.8%). Most of the households had a bed net (85.9%). To have a literate person at home, to belong to the lowland stratum, to have received some type of health education and to own a radio were associated with the knowledge of malaria. A strong association remained between living in the lowland stratum, to own a radio and to live close to the health post and the use of ITN. Being a housewife, lack of health education and to live further than 60 minutes walking distance to the health post were related to a delay on treatment finding.ConclusionThis study has identified some aspects which the MCP might need to improve. The knowledge about malaria transmission should be strengthened. Promotion of literacy and participation in health education are vital components in terms of malaria knowledge and practice. Issues related to geographical location and accessibility to health post should be also carefully examined.

The rate of treatment success in this study was lower than the rate newly recommended by WHO. Therefore, efforts should be undertaken to improve treatment success rates of both diseases.

Summaryobjective To assess the impact and feasibility of artemether-lumefantrine deployment at community level, combined with phased introduction of rapid diagnostic tests (RDTs), on malaria transmission, morbidity, and mortality and health service use in a remote area of Ethiopia.methods Two-year pilot study in two districts: artemether-lumefantrine was prescribed after parasitological confirmation of malaria in health facilities in both districts. In the intervention district, artemether-lumefantrine was also made available through 33 community health workers (CHWs); of these, 50% were equipped with RDTs in the second year.results At health facilities; 54 774 patients in the intervention and 100 535 patients in the control district were treated for malaria. In the intervention district, 75 654 patients were treated for malaria by community health workers. Use of RDTs in Year 2 excluded non-Plasmodium falciparum in 89.7% of suspected cases. During the peak of malaria transmission in 2005, the crude parasite prevalence was 7.4% (95% CI: 6.1-8.9%) in the intervention district and 20.8% (95% CI: 18.7-23.0%) in the control district. Multivariate modelling indicated no significant difference in risk of all-cause mortality between the intervention and the control districts [adjusted incidence rate ratio (aIRR) 1.03, 95%CI 0.87-1.21, P = 0.751], but risk of malaria-specific mortality was lower in the intervention district (aIRR 0.60, 95%CI 0.40-0.90, P = 0.013).conclusions Artemether-lumefantrine deployment through a community-based service in a remote rural population reduced malaria transmission, lowered the malaria case burden for health facilities and reduced malaria morbidity and mortality during a 2-year period which included a major malaria epidemic.

BackgroundMalaria transmission in Ethiopia is unstable and the disease is a major public health problem. Both, p.falciparum (60%) and p.vivax (40%) co-dominantly exist. The national guideline recommends three different diagnosis and treatment strategies at health post level: i) the use of a p.falciparum/vivax specific RDT as diagnosis tool and to treat with artemether-lumefantrine (AL), chloroquine (CQ) or referral if the patient was diagnosed with p.falciparum, p.vivax or no malaria, respectively (parascreen pan/pf based strategy); ii) the use of a p.falciparum specific RDT and AL for p.falciparum cases and CQ for the rest (paracheck pf based strategy); and iii) the use of AL for all cases diagnosed presumptively as malaria (presumptive based strategy). This study aimed to assess the cost-effectiveness of the recommended three diagnosis and treatment strategies in the Tigray region of Ethiopia.MethodsThe study was conducted under a routine health service delivery following the national malaria diagnosis and treatment guideline. Every suspected malaria case, who presented to a health extension worker either at a village or health post, was included. Costing, from the provider's perspective, only included diagnosis and antimalarial drugs. Effectiveness was measured by the number of correctly treated cases (CTC) and average and incremental cost-effectiveness calculated. One-way and two-way sensitivity analyses were conducted for selected parameters.ResultsIn total 2,422 subjects and 35 health posts were enrolled in the study. The average cost-effectiveness ratio showed that the parascreen pan/pf based strategy was more cost-effective (US$1.69/CTC) than both the paracheck pf (US$4.66/CTC) and the presumptive (US$11.08/CTC) based strategies. The incremental cost for the parascreen pan/pf based strategy was US$0.59/CTC to manage 65% more cases. The sensitivity analysis also confirmed parascreen pan/pf based strategy as the most cost-effective.ConclusionThis study showed that the parascreen pan/pf based strategy should be the preferred option to be used at health post level in rural Tigray. This finding is relevant nationwide as the entire country's malaria epidemiology is similar to the study area.