Mesganaw Fantahun

Assessing a new approach to verbal autopsy interpretation in a rural Ethiopian community: the InterVA model

OBJECTIVE Verbal autopsy (VA) -- the interviewing of family members or caregivers about the circumstances of a death after the event -- is an established tool in areas where routine death registration is non-existent or inadequate. We assessed the performance of a probabilistic model (InterVA) for interpreting community-based VA interviews, in order to investigate patterns of cause-specific mortality in a rural Ethiopian community. We compared results with those obtained after review of the VA by local physicians, with a view to validating the model as a community-based tool. METHODS Two-hundred and eighty-nine VA interviews were successfully completed; these included most deaths occurring in a defined community over a 1-year period. The VA interviews were interpreted by physicians and by the model, and cause-specific mortality fractions were derived for the whole community and for particular age groups using both approaches. FINDINGS The results of the two approaches to interpretation correlated well in this example from Ethiopia. Four major cause groups accounted for over 60% of all mortality, and patterns within specific age groups were consistent with expectations for an underdeveloped high-mortality community in sub-Saharan Africa. CONCLUSION Compared with interpretation by physicians, the InterVA model is much less labour intensive and offers 100% consistency. It is a valuable new tool for characterizing patterns of cause-specific mortality in communities without death registration and for comparing patterns of mortality in different populations.

Health and Social Problems Encountered by Treated and Untreated Obstetric Fistula Patients in Rural Ethiopia

OBJECTIVE To assess health, social, and psychological problems encountered by women with treated and untreated obstetric fistula (OF). METHODS A cross-sectional study consisting of quantitative and qualitative components was conducted in seven administrative regions of rural Ethiopia. Fifty-two women with OF were interviewed on the subjects of their socioeconomic status and history of the development of OF. Qualitative in-depth interviews were conducted with 27 of the untreated women and seven of the treated women. RESULTS A total of 19 153 houses were surveyed, and 55 women with fistulae were identified, of whom 52 were interviewed. Thirty-six of the interviewed women (69.2%) were divorced, 10 (19.2%) were not allowed to eat with family members, and 23 (44.2%) were not members of any community associations. Of the 48 women with feelings of depression, 28 (54.2%) had suicidal ideation. Twenty-four women attributed their development of a fistula to evil spirits, to a curse, or to sin. The in-depth interviews revealed that treatment improved family and social life; however, some health, social, and sexual problems remained. CONCLUSION Women with OF encounter health, psychological, and social consequences that are not completely resolved by repairing the fistula. The care of women with OF should go beyond surgical treatment and should include support for their reintegration into the community with proper follow-up.

Women's Involvement in Household Decision-Making and Strengthening Social Capital-Crucial Factors for Child Survival in Ethiopia

Aims: To assess the influence of household decision making, social capital, socio‐economic factors and health service use on under‐five mortality.

The effect of health facility delivery on neonatal mortality: systematic review and meta-analysis

BackgroundThough promising progress has been made towards achieving the Millennium Development Goal four through substantial reduction in under-five mortality, the decline in neonatal mortality remains stagnant, mainly in the middle and low-income countries. As an option, health facility delivery is assumed to reduce this problem significantly. However, the existing evidences show contradicting conclusions about this fact, particularly in areas where enabling environments are constraint. Thus, this review was conducted with the aim of determining the pooled effect of health facility delivery on neonatal mortality.MethodsThe reviewed studies were accessed through electronic web-based search strategy from PUBMED, Cochrane Library and Advanced Google Scholar by using combination key terms. The analysis was done by using STATA-11. I2 test statistic was used to assess heterogeneity. Funnel plot, Begg’s test and Egger’s test were used to check for publication bias. Pooled effect size was determined in the form of relative risk in the random-effects model using DerSimonian and Lairds estimator.ResultsA total of 2,216 studies conducted on the review topic were identified. During screening, 37 studies found to be relevant for data abstraction. From these, only 19 studies fulfilled the preset criteria and included in the analysis. In 10 of the 19 studies included in the analysis, facility delivery had significant association with neonatal mortality; while in 9 studies the association was not significant. Based on the random effects model, the final pooled effect size in the form of relative risk was 0.71 (95% CI: 0.54, 0.87) for health facility delivery as compared to home delivery.ConclusionHealth facility delivery is found to reduce the risk of neonatal mortality by 29% in low and middle income countries. Expansion of health facilities, fulfilling the enabling environments and promoting their utilization during childbirth are essential in areas where home delivery is a common practice.

The effects of pregnancy intention on the use of antenatal care services: systematic review and meta-analysis

BackgroundThere has been considerable debate in the reproductive health literature as to whether unintended pregnancy influences use of maternal health services, particularly antenatal care. Despite the wealth of studies examining the association between pregnancy intention and antenatal care, findings remain mixed and inconclusive. The objective of this study is to systematically review and meta-analyse studies on the association between pregnancy intention and antenatal care.MethodsWe reviewed studies reporting on pregnancy intention and antenatal care from PubMed, Popline, CINHAL and Jstor search engines by developing search strategies. Study quality was assessed for biases in selection, definition of exposure and outcome variables, confounder adjustment, and type of analyses. Adjusted odds ratios, standard errors and sample size were extracted from the included studies and meta-analyzed using STATA version 11. Heterogeneity among studies was assessed using Q test statistic. Effect-size was measured by Odds ratio. Pooled odds ratio for the effects of unintended pregnancy on the use of antenatal care services were calculated using the random effects model.ResultsOur results indicate increased odds of delayed antenatal care use among women with unintended pregnancies (OR 1.42 with 95% CI, 1.27, 1.59) as compared to women with intended pregnancies. Sub-group analysis for developed (1.50 with 95% CI, 1.34, 1.68) and developing (1. 36 with 95% CI, 1.13, 1.65) countries showed significant associations. Moreover, there is an increased odds of inadequate antenatal care use among women with unintended pregnancies as compared to women with intended pregnancies (OR 1.64, 95% CI: 1.47, 1.82). Subgroup analysis for developed (OR, 1.86; 95% CI: 1.62, 2.14) and developing (OR, 1.54; 95% CI: 1.33, 1.77) countries also showed a statistically significant association. However, there were heterogeneities in the studies included in this analysis.ConclusionUnintended pregnancy is associated with late initiation and inadequate use of antenatal care services. Hence, women who report an unintended pregnancy should be targeted for antenatal care counseling and services to prevent adverse maternal and perinatal outcomes. Moreover, providing information on the importance of planning and healthy timing of pregnancies, and the means to do so, to all women of reproductive ages is essential.

Parent-young people communication about sexual and reproductive health in E/Wollega zone, West Ethiopia: Implications for interventions

ObjectivesThis study aims at examining parent-young people communication about sexual and reproductive health related topics and factors associated with it from both young people’s and parents’ perspectives.MethodsA cross-sectional study was conducted among 2,269 young people aged 10–24 years in Nekemte town and semi urban areas, western Ethiopia. Chi-square and multivariate logistic regression analyses were conducted using SPSS for windows version 16. The qualitative data was coded, and categorized in to emerging themes using the open code software version 3.4.ResultAbout a third of young people-32.5% (32.4% of females and 32.7% males) engaged in conversation about sexual and reproductive health topics with their parents/parent figures during the last six months. In logistic regression analyses, young people who were aged 15–19 years were more likely to report parent-communication compared to the other age groups (AOR = 1.57; 95%CI = 1.26-1.97). Female young people are more likely to discuss with their mothers, (AOR = 1.89, 95% CI = 1.13-3.2), sister (AOR = 2.16, 95% CI = 1.19-3.9) and female friends (AOR = 11.7, 95% CI = 7.36-18.7) while males are more likely to discuss with male friends (AOR = 17.3, 95%CI = 10-4-28.6). Educated young people were more likely to parent-communicate(AOR = 1.70, 95%CI = 1.30-2.24). Fear of parent, cultural taboos attached to sex, embarrassments, and parents’ lack of knowledge related to sexual and reproductive health were found to be barriers for parent communication. Parent-communication takes place not only infrequently but also in warning, & threatening way.ConclusionParent-young people communication about sexual health is occurring rarely in the family and bounded by certain barriers. Programmes/policies related to young people’s reproductive health should address not only individual or behavioral factors but also cultural and social factors that negatively influence parent-communication about reproductive health.

Fertility desire and family-planning demand among HIV-positive women and men undergoing antiretroviral treatment in Addis Ababa, Ethiopia

Little information exists about desire to have children and family-planning use among HIV-positive individuals and how this may vary according to individual, social, health and demographic characteristics, especially in developing countries. To assess these topics in Ethiopia, a facility-based cross-sectional study was undertaken among 460 HIV-positive individuals receiving follow-up care at antiretroviral treatment (ART) centres in six public hospitals in Addis Ababa in 2006. One hundred and nine of the women (44.7%), 76 of the men (35.2%), and 40.2% overall of the HIV-positive individuals receiving care desired to have children. In comparison to those who said they did not desire to have children, those who did desire children tended to be younger (18–29 years) (adjusted odds ratio [OR]: 3.05, 95% CI: 1.5–6.4), married or in a relationship (adjusted OR: 3.4, 95% CI: 2.1–5.6), without a child (adjusted OR: 11.5, 95% CI: 5.3–24.9), and with a partner who also desired to have children (adjusted OR: 38.7, 95% CI: 16.7–89.1). Two hundred and forty-six individuals (53.5%) were using family planning (e.g. condoms, abstinence, injectables) and 85 wanted to use family planning in the future. The fertility desire and family-planning needs of these ART clients have implications for preventing vertical and heterosexual transmission of HIV, and the need for appropriate counselling and delivery of services.

Malaria-related mortality based on verbal autopsy in an area of low endemicity in a predominantly rural population in Ethiopia

BackgroundAlthough malaria is one of the most important causes of death in Ethiopia, measuring the magnitude of malaria-attributed deaths at community level poses a considerable difficulty. Nevertheless, despite its low sensitivity and specificity, verbal autopsy (VA) has been the most important technique to determine malaria-specific cause of death for community-based studies. The present study was undertaken to assess the magnitude of malaria mortality in a predominantly rural population of Ethiopia using VA technique at Butajira Rural Health Programme (BRHP) Demographic Surveillance Site (DSS).MethodsA verbal autopsy was carried out for a year from August 2003 to July 2004 for all deaths identified at BRPH-DSS. Two trained physicians independently reviewed each VA questionnaire and indicated the most likely causes of death. Finally, all malaria related deaths were identified and used for analysis.ResultsA verbal autopsy study was successfully conducted in 325 deaths, of which 42 (13%) were attributed to malaria. The majority of malaria deaths (47.6%) were from the rural lowlands compared to those that occurred in the rural highlands (31%) and urban (21.4%) areas. The proportional mortality attributable to malaria was not statistically significant among the specific age groups and ecological zones. Mortality from malaria was reckoned to be seasonal; 57% occurred during a three-month period at the end of the rainy season between September and November. About 71% of the deceased received some form of treatment before death, while 12 (28.6%) of those who died neither sought care from a traditional healer nor were taken to a conventional health facility before death. Of those who sought treatment, 53.3% were first taken to a private clinic, 40% sought care from public health facilities, and the remaining two (6.7%) received traditional medicine. Only 11.9% of the total malaria-related deaths received some sort of treatment within 24h after the onset of illness.ConclusionThe results of this study suggest that malaria plays a considerable role as a cause of death in the study area. Further data on malaria mortality with a relatively large sample size for at least two years will be needed to substantially describe the burden of malaria mortality in the study area.

Young adult and middle age mortality in Butajira demographic surveillance site, Ethiopia: lifestyle, gender and household economy

BackgroundPublic health research characterising the course of life through the middle age in developing societies is scarce. The aim of this study is to explore patterns of adult (15–64 years) mortality in an Ethiopian population over time, by gender, urban or rural lifestyle, causes of death and in relation to household economic status and decision-making.MethodsThe study was conducted in Butajira Demographic Surveillance Site (DSS) in south-central Ethiopia among adults 15–64 years old. Cohort analysis of surveillance data was conducted for the years 1987–2004 complemented by a prospective case-referent (case control) study over two years.Rate ratios were computed to assess the relationships between mortality and background variables using a Poisson regression model. In the case-referent component, odds ratios (95% confidence intervals) were used to assess the effect of certain risk factors that were not included in the surveillance system.ResultsA total of 367 940 person years were observed in a period of 18 years, in which 2 860 deaths occurred. One hundred sixty two cases and 486 matched for age, sex and place of residence controls were included in the case referent (case control) study. Only a modest downward trend in adult mortality was seen over the 18 year period. Rural lifestyle carried a significant survival disadvantage [mortality rate ratio 1.62 (95% CI 1.44 to 1.82), adjusted for gender, period and age group], while the overall effects of gender were negligible. Communicable disease mortality was appreciably higher in rural areas [rate ratio 2.05 (95% CI 1.73 to 2.44), adjusted for gender, age group and period]. Higher mortality was associated with a lack of literacy in a household, poor economic status and lack of womens decision making.ConclusionA complex pattern of adult mortality prevails, still influenced by war, famine and communicable diseases. Individual factors such as a lack of education, low economic status and social disadvantage all contribute to increased risks of mortality.

Mortality measurement in transition: proof of principle for standardised multi-country comparisons*

Objective  To demonstrate the viability and value of comparing cause‐specific mortality across four socioeconomically and culturally diverse settings using a completely standardised approach to VA interpretation.