Miguel San Sebastian

Determinants of antenatal and delivery care utilization in Tigray region, Ethiopia: a cross-sectional study

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.

Factors affecting the use of maternal health services in Madhya Pradesh state of India: a multilevel analysis

BackgroundImproving maternal health is one of the eight Millennium Development Goals. It is widely accepted that the use of maternal health services helps in reducing maternal morbidity and mortality. The utilization of maternal health services is a complex phenomenon and it is influenced by several factors. Therefore, the factors at different levels affecting the use of these services need to be clearly understood. The objective of this study was to estimate the effects of individual, community and district level characteristics on the utilisation of maternal health services with special reference to antenatal care (ANC), skilled attendance at delivery and postnatal care (PNC).MethodsThis study was designed as a cross sectional study. Data from 15,782 ever married women aged 15-49 years residing in Madhya Pradesh state of India who participated in the District Level Household and Facility Survey (DLHS-3) 2007-08 were used for this study. Multilevel logistic regression analysis was performed accounting for individual, community and district level factors associated with the use of maternal health care services. Type of residence at community level and ratio of primary health center to population and percent of tribal population in the district were included as district level variables in this study.ResultsThe results of this study showed that 61.7% of the respondents used ANC at least once during their most recent pregnancy whereas only 37.4% women received PNC within two weeks of delivery. In the last delivery, 49.8% mothers were assisted by skilled personnel. There was considerable amount of variation in the use of maternal health services at community and district levels. About 40% and 14% of the total variance in the use of ANC, 29% and 8% of the total variance in the use of skilled attendance at delivery and 28% and 8.5% of the total variance in the use of PNC was attributable to differences across communities and districts, respectively. When controlled for individual, community and district level factors, the variances in the use of skilled attendance at delivery attributed to the differences across communities and districts were reduced to 15% and 4.3% respectively. There were only marginal reductions observed in the variance at community and district level for ANC and PNC use. The household socio-economic status and mothers education were the most important factors associated with the use of ANC and skilled attendance at delivery. The community level variable was only significant for ANC and skilled attendance at delivery but not for PNC. None of the district level variables used in this study were found to be influential factors for the use of maternal health services.ConclusionsWe found sufficient amount of variations at community and district of residence on each of the three indicators of the use of maternal health services. For increasing the utilisation of these services in the state, in addition to individual-level, there is a strong need to identify and focus on community and district-level interventions.

Pesticide use among farmers in the Amazon basin of Ecuador.

Pesticide use is one of the most significant occupational exposures for agricultural workers in the Amazon basin of Ecuador. A structured questionnaire was developed focusing on sociodemographic characteristics, knowledge and experience of adverse health effects related to pesticide use, details of work practices, and an inventory of pesticides used on the farm. Of the 112 farmers interviewed, 111 (99.1%) used pesticides. Paraquat was most commonly used (77.4%), followed by glyphosate (65.7%). Respondents had good knowledge about the acute health effects of pesticides and their exposure routes. Risk behaviors were identified as frequent pesticide use, washing pesticide equipment in water sources used by humans, inadequate disposal of empty pesticide containers, eating and drinking during pesticide application, and using inadequate protective clothing. Training and educational campaigns on pesticide use should be encouraged for this cohort, along with suggestions for alternative methods of pest control.

Determinants of survival in adult HIV patients on antiretroviral therapy in Oromiyaa, Ethiopia

Background: The antiretroviral treatment (ART) scale-up service has been a recent development in Ethiopia, but its impact on mortality has not been well investigated. The aim of this study was to assess the early survival outcome of the scale-up service by utilizing routine hospital data. Methods: All adult HIV/AIDS patients who started on antiretroviral treatment in Shashemene and Assela hospitals from January 1, 2006 to May 31, 2006 were included and followed up for 2 years. Data were extracted from standard patient medical registrations. Kaplan–Meier curves were used to estimate survival probability and the Cox proportional hazard model was applied to determine predictors of mortality. Two alterative assumptions (real case and worst case) were made in determining predictors of mortality. Results: The median age of patients was 33 years and 57% were female. Eighty-five percent had CD4 <200 cells/µL with a median CD4 count of 103 cells/µL. The median survival time was 104.4 weeks. A total of 28 (10.3%) deaths were observed during the 2-year period and 48 patients (18%) were lost to follow up. The majority of deaths occurred in the first 4 months of treatment. In multivariate analysis, 2-year survival was significantly associated with the clinical stage of the disease, baseline hemoglobin, and cotrimoxazole prophylaxis therapy (CPT) at or before ART initiation in both assumptions. The median CD4 count and body weight showed a marked improvement during the first 6 months of treatment, followed by stagnation thereafter. Conclusion: The study has shown an overall low mortality but a high loss to follow-up rate of the cohort. Advanced clinical stage, anemia, low body weight, and lack of CPT initiation were independent predictors of mortality – but not gender. CPT initiation should be encouraged in routine HIV care services, and patient retention mechanisms have to be strengthened. Stagnation in immunological and weight recovery after the first 6 months should be further investigated. The utilization of routine data should be encouraged in order to facilitate appropriate decision making.

Incidence of childhood leukemia and oil exploitation in the Amazon basin of Ecuador.

Abstract To determine whether there was any difference in childhood leukemia incidence rates between populations living in the proximity to oil fields and those living in areas free from oil exploitation in the Amazon basin of Ecuador, 91 cancer cases among children (0–14 years) from the provinces of Sucumbios, Orellana, Napo, and Pastaza during the period 1985–2000 were studied. The relative risks for all leukemias indicated significantly elevated levels in the youngest age group (0–4 years), both genders combined (RR 3.48, 95% CI 1.25–9.67), and in all age groups (0–14 years) combined for females (RR 2.60, 95% CI 1.11–6.08) and both genders combined (RR 2.56,95% CI 1.35–4.86). There was no significant difference between the two groups in all other cancer sites combined. Study results are compatible with a relationship between childhood leukemia incidence and living in the proximity of oil fields in the Ecuadorian Amazon.

Outcomes of pregnancy among women living in the proximity of oil fields in the Amazon basin of Ecuador.

Abstract Oil companies have released billions of gallons of untreated wastes and oil directly into the environment of the Ecuadorian Amazon. This cross-sectional study investigated the environmental conditions and reproductive health of women living in rural communities surrounded by oil fields in the Amazon basin and in unexposed communities. Water from local streams was analyzed for total petroleum hydrocarbons (TPH). The women, aged 17 to 45 years, had resided for at least three years in the study communities. Socioeconomic and reproductive histories of the last three pregnancies were obtained from interviews. Information from the questionnaire was available for 365 exposed and 283 non-exposed women. The study was conducted from November 1998 to April 1999. Streams of exposed communities had TPH concentrations above the allowable limit. Mter adjustment for potential confounders, the pregnancies of women in exposed communities were more likely to end in spontaneous abortion (OR: 2.47;95% CI: 1.61–3.79;P < 0.01). No association was found between stillbirth and exposure. An environmental systemto control and eliminate the sources of pollution in the area is needed.

Making pragmatic choices: women’s experiences of delivery care in Northern Ethiopia

BackgroundIn 2003, the Ethiopian Ministry of Health launched the Health Extension Programme (HEP), which was intended to increase access to reproductive health care. Despite enormous effort, utilization of maternal health services remains limited, and the reasons for the low utilization of the services offered through the HEP previously have not been explored in depth.This study explores women’s experiences and perceptions regarding delivery care in Tigray, a northern region of Ethiopia, and enables us to make suggestions for better implementation of maternal health care services in this setting.MethodsWe used six focus group discussions with 51 women to explore perceptions and experiences regarding delivery care. The data were analysed by means of grounded theory.ResultsOne core category emerged, ‘making pragmatic choices’, which connected the categories ‘aiming for safer deliveries’, ‘embedded in tradition’, and ‘medical knowledge under constrained circumstances’. In this setting, women – aiming for safer deliveries – made choices pragmatically between the two available models of childbirth. On the one hand, choice of home delivery, represented by the category ‘embedded in tradition’, was related to their faith, the ascendancy of elderly women, the advantages of staying at home and the custom of traditional birth attendants (TBAs). On the other, institutional delivery, represented by the category ‘medical knowledge under constrained circumstances’, and linked to how women appreciated medical resources and the support of health extension workers (HEWs) but were uncertain about the quality of care, emphasized the barriers to transportation.In Tigray women made choices pragmatically and seemed to not feel any conflict between the two available models, being supported by traditional birth attendants, HEWs and husbands in their decision-making. Representatives of the two models were not as open to collaboration as the women themselves, however.ConclusionsAlthough women did not see any conflict between traditional and institutional maternal care, the gap between the models remained and revealed a need to reconcile differing views among the caregivers. The HEP would benefit from an approach that incorporates all the actors involved in maternal care, at institutional, community and family levels alike. Reconsideration is required of the role of TBAs, and a well-designed, community-inclusive, coordinated and feasible referral system should be maintained.

Decentralization and health care prioritization process in Tanzania: from national rhetoric to local reality.

During the 1990s, Tanzania like many other developing countries adopted health sector reforms. The most common policy change under the health sector reforms has been decentralization, which involves the transfer of power and authority from the central level to local authorities. Based on the case study of Mbarali district in Tanzania, this paper uses a policy analysis approach to analyse the implementation of decentralized health care priority setting. Specifically, the paper examines the process, actors and contextual factors shaping decentralized health care priority setting processes. The analysis and conclusion are based on a review of documents, key informant interviews, focus group discussion, and notes from non-participant observation. The findings of the study indicate that local institutional contexts and power asymmetries among actors have a greater influence on the prioritization process at the local level than expected and intended. The paper underlines the essentially political character of the decentralization process and reiterates the need for policy analysts to pay attention to processes, institutional contexts, and the role of policy actors in shaping the implementation of the decentralization process at the district level.

Economic crisis and suicidal behaviour: the role of unemployment, sex and age in Andalusia, Southern Spain

IntroductionAlthough suicide rates have increased in some European countries in relation to the current economic crisis and austerity policies, that trend has not been observed in Spain. This study examines the impact of the economic crisis on suicide attempts, the previously neglected endpoint of the suicidal process, and its relation to unemployment, age and sex.MethodsThe study was carried out in Andalusia, the most populated region of Spain, and which has a high level of unemployment. Information on suicide attempts attended by emergency services was extracted from the Health Emergencies Public Enterprise Information System (SIEPES). Suicide attempts occurring between 2003 and 2012 were included, in order to cover five years prior to the crisis (2003–2007) and five years after its onset (2008–2012). Information was retrieved from 24,380 cases (11,494 men and 12,886 women) on sex, age, address, and type of attention provided. Age-adjusted suicide attempt rates were calculated. Excess numbers of attempts from 2008 to 2012 were estimated for each sex using historical trends of the five previous years, through time regression models using negative binomial regression analysis. To assess the association between unemployment and suicide attempts rates, linear regression models with fixed effects were performed.ResultsA sharp increase in suicide attempt rates in Andalusia was detected after the onset of the crisis, both in men and in women. Adults aged 35 to 54 years were the most affected in both sexes. Suicide attempt rates were associated with unemployment rates in men, accounting for almost half of the cases during the five initial years of the crisis. Women were also affected during the recession period but this association could not be specifically attributed to unemployment.ConclusionsThis study enhances our understanding of the potential effects of the economic crisis on the rapidly increasing suicide attempt rates in women and men, and the association of unemployment with growing suicidal behaviour in men. Research on the suicide effects of the economic crisis may need to take into account earlier stages of the suicidal process, and that this effect may differ by age and sex.Resumen (Spanish/Español)IntroducciónA pesar de que las tasas de suicidio han aumentado en algunos países europeos en relación con la crisis económica actual y las políticas de austeridad, esa tendencia no se ha observado en España. Este trabajo examina el impacto de la crisis económica sobre los intentos de suicidio, punto final del proceso suicida poco estudiado hasta ahora, y su relación con desempleo, edad y sexo.MétodosEl estudio fue llevado a cabo en Andalucía, la región más poblada de España, y con un alto nivel de desempleo. La información sobre los intentos de suicidio atendidos por los servicios de emergencia se obtuvo del Sistema de Información de la Empresa Pública de Emergencias de Salud (SIEPES). Se incluyeron los intentos de suicidio ocurridos entre 2003 y 2012, con el fin de cubrir los cinco años anteriores a la crisis (2003–2007) y cinco años desde su inicio (2008–2012). Se recuperó información de 24 380 casos (11 494 hombres y 12 886 mujeres) sobre sexo, edad, dirección y tipo de atención recibida. Se calcularon las tasas de intentos de suicidio ajustadas por edad. Se estimó el exceso de intentos de suicidio en 2008–2012 para cada sexo utilizando las tendencias históricas de los cinco años anteriores con modelos de regresión temporal mediante regresión binomial negativa. Para evaluar la asociación entre el desempleo y las tasas de intentos de suicidio se ajustaron modelos de regresión lineal con efectos fijos.ResultadosSe detectó un importante aumento de las tasas de intento de suicidio en Andalucía tras el comienzo de la crisis, tanto en hombres como en mujeres. Los adultos de 35 a 54 años fueron los más afectados en ambos sexos. Los intentos de suicidio se asociaron con el nivel de desempleo en los hombres, explicando casi la mitad de los casos durante los cinco primeros años de la crisis. Las mujeres también se vieron afectadas durante el período de recesión, pero el incremento de los intentos de suicidio no pudo atribuirse específicamente al desempleo.ConclusionesEste estudio mejora nuestra comprensión de los efectos potenciales de la crisis económica sobre el rápido aumento de los intentos de suicidio en mujeres y hombres, y de la asociación del desempleo con el auge de la conducta suicida en los hombres. La investigación del impacto de la crisis económica sobre el suicidio debe tener en cuenta las etapas iniciales del proceso suicida, y que sus efectos pueden manifestarse de forma diferente según edad y sexo.

Efficiency of the health extension programme in Tigray, Ethiopia: a data envelopment analysis

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.