BackgroundNeonatal mortality accounts for an estimated 2.8 million deaths worldwide, which constitutes 44 % of under-5-mortality and 60 % of infant mortality. Neonatal mortality predictors vary by country with the availability and quality of health care. Therefore, aim of this study was to estimate survival time and identify predictors of neonatal mortality in Tigray region, northern Ethiopia.MethodA prospective cohort study design was carried out among a cohort of neonates delivered in seven hospitals of Tigray from April to July, 2014 and followed up for a total of 28 days. Data were collected by interviewing mothers using structured questionnaires and assessments of the neonate and mothers by midwives. Kaplan-Meier, Log rank test and Cox-proportional hazard regressions were used. STATA V-11 program was used for data entry, cleaning and analysis.ResultsFrom 1152 neonates, 68 died (neonatal mortality rate 62.5/1000 live births), 73.52 % of the neonates died within 7 days, 60 were lost to follow-up and the percentage of survival at 28 days was 93.96 % (95 % CI: 92.4, 95.2 %). Predictors of neonatal mortality were: normal birth weight (AHR: 0.45, 95 % CI: 0.24, 0.84), not initiating exclusive breastfeeding (AHR: 7.5, 95 % CI: 3.77, 15.05), neonatal complications (AHR: 0.14, 95 % CI 0.07, 0.29), maternal complications (AHR: 0.37, 95 % CI: 0.22, 0.63) and proximity (AHR: 2.5, 95 % CI: 1.29, 4.91).ConclusionNeonatal mortality is unacceptably very high. Managing complications and low birth weight, initiating exclusive breast feeding, improving quality of services and ensuring a continuum of care are recommended to increase survival of neonates.

BackgroundImproving maternal health is one of the eight millennium development goals to reduce maternal mortality (MM) by three quarters between 1990 and 2015. Institutional delivery is considered to be the most critical intervention in reducing MM and ensuring safe motherhood. However, the level of maternal morbidity and mortality in Ethiopia are among the highest in the world and the proportion of births occurring at health facilities is very low. This study examined the individual and community level factors associated with institutional delivery in Ethiopia.MethodsData from the 2011 Ethiopian demographic and health survey were used to identify individual and community level factors associated with institutional delivery among women who had a live birth during the 5 years preceding the survey. Taking into account the nested structure of the data, multilevel logistic regression analysis has been employed to a nationally representative sample of 7757 women nested with in 595 communities.ResultsAt the individual level; higher educational level of the women (AOR = 3.60; 95 % CI 2.491–5.214), women from richest households (AOR = 1.74; 95 % CI 1.143–2.648) and increased ante natal care attendance (AOR = 4.43; 95 % CI 3.405–5.751) were associated with institutional delivery. Additionally, at the community level; urban residence (AOR = 4.74; 95 % CI 3.196–7.039), residing in communities with high proportion of educated women (AOR = 1.71; 95 % CI 1.256–2.319) and residing in communities with high ANC utilization rate (AOR = 1.55; 95 % CI 1.132–2.127) had a significant effect on institutional delivery. Also region and distance to health facility showed significant association with institutional delivery. The random effects showed that the variation in institutional delivery service utilization between communities was statistically significant.ConclusionBoth individual and community level factors are associated with institutional delivery service uptake. As a result, further research is needed to better understand why these factors may affect institutional delivery.

BackgroundTuberculosis (TB) is a major public health problem that accounts for almost half a million human immunodeficiency virus (HIV) associated deaths. Provision of isoniazid preventive therapy (IPT) is one of the public health interventions for the prevention of TB in HIV infected individuals. However, in Ethiopia, the coverage and implementation of IPT is limited. The objective of this study is to compare the incidence rate of TB, TB-free survival time and identify factors associated with development TB among HIV-infected individuals on pre-ART follow up.MethodsA retrospective cohort study was conducted from January, 2008 to February 31, 2012 in Jimma hospital. Kaplan-Meier survival plots were used to calculate the crude effect in both groups on TB-free survival probabilities and compared using the log rank test. A Cox proportional hazard model was used to identify predictors of TB.ResultA total of 588 patients on pre-ART care (294 IPT and 294 non-IPT group) were followed retrospectively for a median duration of 24.1 months. The median CD4+ cell count was 422 cells/μl (IQR 344 – 589). During the follow up period, 49 individuals were diagnosed with tuberculosis, giving an overall incidence of 3.78 cases per 100 person year (PY). The incidence rate of TB was 5.06 per 100 PY in non-IPT group and 2.22 per 100 PY in IPT user group. Predictors of higher TB risk were: being on clinical WHO stage III/IV (adjusted hazard ratio (AHR = 3.05, 95% confidence interval (CI): 1.61, 5.81); non-IPT user (AHR = 2.02, 95% CI: 1.04, 3.92); having CD4+ cell count less than 350 cells/μl (AHR = 3.16, 95% CI: 1.04, 3.92) and between 350–499 cells/μl, (AHR = 2.87; 95% CI: 1.37 - 6.03) and having episode of opportunistic infection (OI) in the past (AHR = 2.41, 95% CI: 1.33-4.34).ConclusionIPT use was associated with fifty percent reduction in new cases of tuberculosis and probability of developing TB was higher in non-IPT group. Implementing the widespread use of IPT has the potential to reduce TB rates substantially among HIV-infected individuals in addition to other tuberculosis prevention and control effort in resource limited settings.

ObjectiveLinkage to care is the bridge between HIV testing and HIV treatment, care and support. In Tanzania, mobile testing aims to address historically low testing rates. Linkage to care was reported at 14% in 2009 and 28% in 2014. The study compares linkage to care of HIV-positive individuals tested at mobile/outreach versus public health facility-based services within the first 6 months of HIV diagnosis.SettingRural communities in four districts of Mbeya Region, Tanzania.ParticipantsA total of 1012 newly diagnosed HIV-positive adults from 16 testing facilities were enrolled into a two-armed cohort and followed for 6 months between August 2014 and July 2015. 840 (83%) participants completed the study.Main outcome measuresWe compared the ratios and time variance in linkage to care using the Kaplan-Meier estimator and Log rank tests. Cox proportional hazards regression models to evaluate factors associated with time variance in linkage.ResultsAt the end of 6 months, 78% of all respondents had linked into care, with differences across testing models. 84% (CI 81% to 87%, n=512) of individuals tested at facility-based site were linked to care compared to 69% (CI 65% to 74%, n=281) of individuals tested at mobile/outreach. The median time to linkage was 1 day (IQR: 1–7.5) for facility-based site and 6 days (IQR: 3–11) for mobile/outreach sites. Participants tested at facility-based site were 78% more likely to link than those tested at mobile/outreach when other variables were controlled (AHR=1.78; 95% CI 1.52 to 2.07). HIV status disclosure to family/relatives was significantly associated with linkage to care (AHR=2.64; 95% CI 2.05 to 3.39).ConclusionsLinkage to care after testing HIV positive in rural Tanzania has increased markedly since 2014, across testing models. Individuals tested at facility-based sites linked in significantly higher proportion and modestly sooner than mobile/outreach tested individuals. Mobile/outreach testing models bring HIV testing services closer to people. Strategies to improve linkage from mobile/outreach models are needed.

Background In remote rural Tanzania, the rate of linkage into HIV care was estimated at 28% in 2014. This study explored facilitators and barriers to linkage to HIV care at individual/patient, health care provider, health system, and contextual levels to inform eventual design of interventions to improve linkage to HIV care. Methods We conducted a descriptive qualitative study nested in a cohort study of 1012 newly diagnosed HIV-positive individuals in Mbeya region between August 2014 and July 2015. We conducted 8 focus group discussions and 10 in-depth interviews with recently diagnosed HIV-positive individuals and 20 individual interviews with healthcare providers. Transcripts were analyzed inductively using thematic content analysis. The emergent themes were then deductively fitted into the four level ecological model. Results We identified multiple factors influencing linkage to care. HIV status disclosure, support from family/relatives and having symptoms of disease were reported to facilitate linkage at the individual level. Fear of stigma, lack of disclosure, denial and being asymptomatic, belief in witchcraft and spiritual beliefs were barriers identified at individual’s level. At providers’ level; support and good patient-staff relationship facilitated linkage, while negative attitudes and abusive language were reported barriers to successful linkage. Clear referral procedures and well-organized clinic procedures were system-level facilitators, whereas poorly organized clinic procedures and visit schedules, overcrowding, long waiting times and lack of resources were reported barriers. Distance and transport costs to HIV care centers were important contextual factors influencing linkage to care. Conclusion Linkage to HIV care is an important step towards proper management of HIV. We found that access and linkage to care are influenced positively and negatively at all levels, however, the individual-level and health system-level factors were most prominent in this setting. Interventions must address issues around stigma, denial and inadequate awareness of the value of early linkage to care, and improve the capacity of HIV treatment/care clinics to implement quality care, particularly in light of adopting the ‘Test and Treat’ model of HIV treatment and care recommended by the World Health Organization.

Background: Pre-term and post-term births are major determinants of neonatal mortality, including short-and long-term morbidity. In developing countries, where pre-term and post-term births are disproportionately common, the magnitude and underlying causes are not well understood, and evidence is required to design appropriate interventions. This study measured the incidence and identified risk factors of pre-term birth and post-term births in Ethiopia. In addition, it examined the effects of pre-term and post-term birth on neonatal mortality. Method: This study is a portion of prospective cohort study conducted on 1152 live births born between April and July 2014 in seven hospitals in Tigray region, Northern Ethiopia. Neonatal mortality and birth outcomes were considered as dependent variables. Data were collected using a structured questionnaire and weekly neonatal follow up directed at midwives. Data were described using frequency, percentage, ratio of relative risk (RRR), and 95 % confidence interval (CI). We used multinomial and binary logistic regression to identify independent predictors of birth outcome and neonatal mortality respectively. Result: The prevalence of pre-term and post term births was 8.1 % and 6.0 % respectively. Underweight maternal body mass index (RRR: 0.47, CI: 0.22-0.99), medium reported income (RRR: 0.26, CI: 0.12-0.5), length of neonate (RRR: 0.05, CI: 0.01-0.41), and multiple births (RRR: 2.86, CI: 1.4-5.650) were associated with pre-term birth. Predictors for post-term birth were overweight maternal body mass index (RRR: 3.88, CI: 1.01-15.05), high reported income mothers (RRR: 2.17, CI:1.1-4.3), as well as unmarried, widowed and divorced marital status (RRR:2.43, CI:1.02-5.80). With regards to binary logistic regression, pre-term birth (RR: 2.45, CI: 1.45-4.04) was an independent predictor for neonatal mortality, but this was not true for post-term births (RR: 0.45, CI: 0.07-2.96). Conclusion: Socioeconomic and proximate factors are important predictors for pre-term and post-term births. Empowering women in terms of income status and controlling body mass index within the normal range are recommended. In addition, early detection and close antenatal follow-ups for mothers, who are at risk before and during pregnancy, are necessary to prevent both pre-term and post-term births.

Background: Antenatal care (ANC) is attention given to a pregnant mother from the time of conception until the beginning of labor. It has an impact on the development of the fetus as well as the health of the mother. It can be achieved through early booking and regular attendance of antenatal clinic. Objective: This study assessed the magnitude and associated factors for late booking for antenatal care in Adigrat town. Methodology: A facility based cross-sectional study was employed to collect data from 415 pregnant women using face-to-face interview. Descriptive statistics, Bivariate and multivariate binary logistic regression analysis were used to identify associated factors with late booking for ANC. Result: Two hundred fifteen (51.8%) pregnant women booked their first ANC late. The multivariate logistic regression analysis showed that pregnant women who had parity one and above, unplanned pregnancy and those who had a perception time to book ANC is after four months of gestational age were increased but having no history on abortion decreased the likelihood of late booking than the reference category. Conclusion: The prevalence of late booking for ANC was found high in Adigrat and the possible factors for this were parity one and above, had no history of abortion, unplanned pregnancy and perception the time to book ANC. To improve this addressing the identified factors by community mobilization and promoting the importance of early booking for ANC are mandatory.

BackgroundPrevention of mother to child HIV transmission (PMTCT) remains a challenge in low and middle-income countries. Determinants of utilization occur – and often interact - at both individual and community levels, but most studies do not address how determinants interact across levels. Multilevel models allow for the importance of both groups and individuals in understanding health outcomes and provide one way to link the traditionally distinct ecological- and individual-level studies. This study examined individual and community level determinants of mother and child receiving PMTCT services in Tigray region, Ethiopia.MethodsA multistage probability sampling method was used for this 2011 cross-sectional study of 220 HIV positive post-partum women attending child immunization services at 50 health facilities in 46 districts. In view of the nested nature of the data, we used multilevel modeling methods and assessed macro level random effects.ResultsSeventy nine percent of mothers and 55.7% of their children had received PMTCT services. Multivariate multilevel modeling found that mothers who delivered at a health facility were 18 times (AOR = 18.21; 95% CI 4.37,75.91) and children born at a health facility were 5 times (AOR = 4.77; 95% CI 1.21,18.83) more likely to receive PMTCT services, compared to mothers delivering at home. For every addition of one nurse per 1500 people, the likelihood of getting PMTCT services for a mother increases by 7.22 fold (AOR = 7.22; 95% CI 1.02,51.26), when other individual and community level factors were controlled simultaneously. In addition, district-level variation was low for mothers receiving PMTCT services (0.6% between districts) but higher for children (27.2% variation between districts).ConclusionsThis study, using a multilevel modeling approach, was able to identify factors operating at both individual and community levels that affect mothers and children getting PMTCT services. This may allow differentiating and accentuating approaches for different settings in Ethiopia. Increasing health facility delivery and HCT coverage could increase mother-child pairs who are getting PMTCT. Reducing the distance to health facility and increasing the number of nurses and laboratory technicians are also important variables to be considered by the government.