Mengistu Asnake

Quality of life of Ethiopian women after fistula repair: implications on rehabilitation and social reintegration policy and programming

Despite growing recognition of the importance of linking obstetric fistula prevention and treatment strategies with rehabilitation and social reintegration programmes, little research and programming has been oriented toward this goal. Using in-depth interviews, this study aimed to examine the experiences of 51 Ethiopian women after fistula repair surgery to identify priority post-repair interventions that could maximise their quality of life. The results showed that the majority of women felt a dramatic sensation of relief and happiness following repair, yet some continued to experience mental anguish, stigma, and physical problems regardless of the outcome of the procedure. All women suffered intense fear of developing another fistula, most commonly from sex or childbirth. Despite this, the majority of women had sex or planned to do so, while a smaller cohort avoided intercourse and childbearing, thus subjecting them to isolation, marital conflict, and/or economic vulnerability. Our findings suggest that obstetric fistula programmes should integrate (1) post-repair counselling about fistula and risk factors for recurrence, (2) community-based follow-up care, (3) linkages to income-generating opportunities, (4) engagement of women affected by fistula for community outreach, and (5) metrics for evaluating rehabilitation and social reintegration efforts to ensure women regain healthy, productive lives.

Addressing unmet need for long-acting family planning in Ethiopia: Uptake of single-rod progestogen contraceptive implants (Implanon) and characteristics of users

To describe women who accept single‐rod progestogen contraceptive implants (Implanon; N.V. Organon, Oss, Netherlands) from community health workers in Ethiopia and to assess whether community‐based provision addresses unmet need for contraception.

The Single-Visit Approach as a Cervical Cancer Prevention Strategy Among Women With HIV in Ethiopia: Successes and Lessons Learned

With the single-visit approach for cervical cancer prevention, women with positive “visual inspection of the cervix with acetic acid wash” (VIA) test results receive immediate treatment of the precancerous lesion with cryotherapy. The approach worked successfully for women with HIV in Ethiopia in secondary and tertiary health facilities, with high screening and cryotherapy treatment rates. Sustainability and appropriate scale-up of such programs must address wider health system challenges including human resource constraints and shortage of essential supplies. With the single-visit approach for cervical cancer prevention, women with positive “visual inspection of the cervix with acetic acid wash” (VIA) test results receive immediate treatment of the precancerous lesion with cryotherapy. The approach worked successfully for women with HIV in Ethiopia in secondary and tertiary health facilities, with high screening and cryotherapy treatment rates. Sustainability and appropriate scale-up of such programs must address wider health system challenges including human resource constraints and shortage of essential supplies. ABSTRACT Introduction: Cervical cancer is the second most common form of cancer for women in Ethiopia. Using a single-visit approach to prevent cervical cancer, the Addis Tesfa (New Hope) project in Ethiopia tested women with HIV through visual inspection of the cervix with acetic acid wash (VIA) and, if tests results were positive, offered immediate cryotherapy of the precancerous lesion or referral for loop electrosurgical excision procedure (LEEP). The objective of this article is to review screening and treatment outcomes over nearly 4 years of project implementation and to identify lessons learned to improve cervical cancer prevention programs in Ethiopia and other resource-constrained settings. Methods: We analyzed aggregate client data from August 2010 to March 2014 to obtain the number of women with HIV who were counseled, screened, and treated, as well as the number of annual follow-up visits made, from the 14 tertiary- and secondary-level health facilities implementing the single-visit approach. A health facility assessment (HFA) was also implemented from August to December 2013 to examine the effects of the single-visit approach on client flow, staff workload, and facility infrastructure 3 years after initiating the approach. Results: Almost all (99%) of the 16,632 women with HIV counseled about the single-visit approach were screened with VIA during the study period; 1,656 (10%) of them tested VIA positive (VIA+) for precancerous lesions. Among those who tested VIA+ and were thus eligible for cryotherapy, 1,481 (97%) received cryotherapy treatment, but only 80 (63%) women eligible for LEEP actually received the treatment. The HFA results showed frequent staff turnover, some shortage of essential supplies, and rooms that were judged by providers to be too small for delivery of cervical cancer prevention services. Conclusion: The high proportions of VIA screening and cryotherapy treatment in the Addis Tesfa project suggest high acceptance of such services by women with HIV and feasibility of implementation in secondary- and tertiary-level health facilities. However, success of cervical cancer prevention programming must address wider health system challenges to ensure sustainability and appropriate scale-up to the general population of Ethiopia and other resource-constrained settings.

Expanding Access to the Intrauterine Device in Public Health Facilities in Ethiopia: A Mixed-Methods Study

Following the introduction of IUDs into the Ethiopian public health sector, use of the method increased from <1% in 2011 to 6% in 2014 in a sample of 40 health facilities. This shift occurred in the context of wide method choice, following provider training, provision of post-training supplies, and community-based awareness creation. The IUD was acceptable to a diverse range of clients, including new contraceptive users, those with little to no education, those from rural areas, and younger women, thus suggesting a strong latent demand for IUDs in Ethiopia. Following the introduction of IUDs into the Ethiopian public health sector, use of the method increased from <1% in 2011 to 6% in 2014 in a sample of 40 health facilities. This shift occurred in the context of wide method choice, following provider training, provision of post-training supplies, and community-based awareness creation. The IUD was acceptable to a diverse range of clients, including new contraceptive users, those with little to no education, those from rural areas, and younger women, thus suggesting a strong latent demand for IUDs in Ethiopia. ABSTRACT In Ethiopia, modern contraceptive prevalence among currently married women nearly tripled over the last decade, but the method mix remains skewed toward short-acting methods. Since 2011, the Integrated Family Health Program (IFHP+), jointly implemented by Pathfinder International and John Snow Inc., has supported the Federal Ministry of Health to introduce intrauterine devices (IUDs) in more than 800 health centers across 4 regions to improve access to a wider range of methods. Between March and August 2014, Pathfinder conducted a mixed-methods study in 40 purposively selected health centers to assess shifts in the contraceptive method mix following introduction of IUDs using data from family planning registers; determine the characteristics of IUD users through a cross-sectional survey of 2,943 family planning clients who accepted the IUD; explore reasons for method discontinuation among 165 clients seeking IUD removal services; and identify facilitators and barriers to IUD use through focus group discussions (N = 115 clients) and key informant interviews (N = 36 providers, facility heads, and health office heads). Introduction of IUDs into the 40 health centers participating in the study was correlated with a statistically significant increase in the contribution of all long-acting reversible contraceptives (LARCs)—both IUDs and implants—to the method mix, from 6.9% in 2011 to 20.5% in 2014 (P<.001). Our study found that latent demand for the IUD was more prevalent than anticipated and that the method was acceptable to a broad cross-section of women. Of the 2,943 women who sought IUDs during the 6-month study period, 18.0% were new contraceptive users (i.e., those using a contraceptive method for the first time ever), 44.7% reported no educational attainment, 62.5% were from rural areas, and 59.3% were younger than 30 years old, with almost 3 in 10 (27.7%) under the age of 25. The most commonly cited reason for seeking IUD removal services was a desire to become pregnant (43% of women). Qualitative data indicated that while acceptability of the method is growing, limited community awareness, myths and misconceptions about the IUD, and infrastructure deficits at health centers must be addressed to further expand access to a broad range of contraceptive methods.

Knowledge and Awareness of Cervical Cancer among HIV-Infected Women in Ethiopia

Introduction. Cervical cancer is one of the leading causes of cancer death among Ethiopian women. Low awareness of cervical cancer, in combination with low health care seeking behavior, is a key challenge for cervical cancer prevention. This study assessed the knowledge of cervical cancer among HIV-infected women in Ethiopia. Methods. A facility-based cross-sectional survey was conducted from August to September 2012 among HIV-infected women between 21 and 49 years of age. Basic descriptive statistics were performed using SPSS. Results. A total of 432 HIV-infected women participated in this study. About 71% of participants had ever heard of cervical cancer. Among women who had ever heard of cervical cancer, 49% did not know the cause while 74% were able to identify at least one risk factor for cervical cancer. Only 33% of women were able to correctly address when women should seek care and 33% identified at least one treatment option for cervical cancer. Conclusion. This study revealed that knowledge about cervical cancer was generally low, in particular for health care seeking behavior and treatment of cervical cancer. Health awareness programs should be strengthened at both community and health facility levels with emphasis highlighting the causes, risk factors, care seeking behaviors, and treatment options for cervical cancer.

The Status of Desired Maternal and Child Health Practices and Service Utilizations of Model Families of the Health Extension Program in SNNPR, Ethiopia

Background: Maternal and Child Health (MCH) is one of the main focus areas of the Health Extension Program (HEP). Therefore, assessing the status of MCH service utilization of families benefiting from the HEP is critical to inform progress of the program and future directions. Objective: The purpose of this study is to assess the status of desired MCH practices and service utilization of families benefiting from the HEP in SNNPR state of Ethiopia. Method: A cross-sectional comparative study was conducted from December 2010 to June 2011 in Wolayta and Kembata Tembaro Zones of Southern Nations, Nationalities and Peoples Regional State of Ethiopia. Comparison of selected variables that show MCH service utilization was made between a randomly selected 690 model families and 686 non-model families. Qualitative data were collected from the two selected zones to complement the findings of the quantitative data. The qualitative data was collected from a purposively selected group of women and men among model families. Descriptive and analytics statistics were used to analyse the quantitative data using STATA version 10 while the qualitative data were analysed using Open Code version 3.6.2.0. Results: The study showed that ITN ownership and utilization by model families was 66.9% and 58.4% as compared to 53.3% and 42.6% by non-model families respectively (p<0.01). Similarly, ever and current use of family planning was 45.4% and 32.3% as compared to 33.6% and 18.6% among model and non-model families respectively (p<0.001). Nearly half (47.3%) of the women in model families had ever tested for HIV while 35.2% of the women in non-model families did the same (P<0.01). Forty two point three Percent (42.3%) of husbands in model families also tested for HIV while only 35.8% of their counterparts in non-model families did the same (p<0.01). There was no significant difference in the proportion of households with child immunization and feeding practices between model and non-model families. Conclusion: Generally, model families performed better than non-model families. The government’s decision of making all households models through the implementation of the health development army is a timely decision. Regular follow up of model families after graduation help further improve outcome and sustain the gains.

Improving Contraceptive Access, Use, and Method Mix by Task Sharing Implanon Insertion to Frontline Health Workers: The Experience of the Integrated Family Health Program in Ethiopia

Between 2009 and 2015, 1.2 million women received Implanon implants from trained Health Extension Workers. Of the approximately 7,000 implant service visits made during the first 6 months, 25% were among women who had never used contraception before. Between 2009 and 2015, 1.2 million women received Implanon implants from trained Health Extension Workers. Of the approximately 7,000 implant service visits made during the first 6 months, 25% were among women who had never used contraception before. In 2009, the Ethiopian Federal Ministry of Health launched an Implanon scale-up program with the goal of improving the availability of long-acting reversible contraceptive (LARC) methods at the community level. The Integrated Family Health Program (IFHP) supported the ministry to train Health Extension Workers (HEWs), a cadre of frontline health workers, on Implanon insertion. Prior to this task-sharing initiative, HEWs were only permitted to provide short-acting contraceptive methods; Implanon insertion services were only available at higher-level health facilities, such as health centers and above. To train HEWs on Implanon insertion, IFHP followed a phase-based approach, which consisted of a learning phase (July to September 2009) that transitioned into a scale-up phase (December 2009 to December 2015). Training began with a series of service delivery-based training of trainers (TOT) sessions for clinical care providers selected from health centers followed by rollout trainings on Implanon insertion for HEWs selected from health posts. Immediately after the Implanon rollout trainings, each trained HEW was provided with consumables and Implanon implants to enable them to initiate the Implanon services at their respective health post. To reinforce knowledge and skills, we conducted mentoring visits and performance review meetings. From July 2009 to September 2015, 98 TOT sessions trained 2,328 clinicians and 320 rollout trainings reached 8,436 HEWs. A total of 1,382,318 women received contraceptive services through any IFHP-supported service delivery point, 1,273,990 of whom received an Implanon implant. The IFHP approach proved to be a successful model for increasing access to contraceptive methods in the community, and the program supported the integration of Implanon services into the existing public health service delivery system.