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Background Intimate partner violence (IPV) is an important public health and human rights issue with high prevalence in Nigeria. Understanding the link between IPV and breastfeeding—an important intervention to reduce child morbidity and mortality—is critical and could inform strategies to promote breastfeeding and reduce IPV. This study examines the association between recent maternal experience of IPV and optimal breastfeeding of children aged 0 to 23 months in Nigeria. Methods This secondary analysis of the 2018 Nigeria Demographic and Health Survey included a sample of 3,749 women aged 15 – 49 years who had singleton live birth in the two years preceding the survey. The outcome variable was optimal breastfeeding for age (exclusive breastfeeding in the first six months of life and any breastfeeding from 6-23 months). We defined recent IPV as exposure to any IPV in the 12 months preceding the survey; we also included the number of forms of IPV experienced (0, 1, 2 or 3: physical, emotional, and sexual) as an additional categorical independent variable. We used frequencies and proportions to describe key variables. We then conducted two multivariable logistic regression models—with any IPV and number of forms of IPV to determine the crude and adjusted odds ratios between IPV and optimal breastfeeding for age. Results Among all women, 31% experienced any IPV and 2.6% all three forms. Nearly one-third (31.7%) of babies Conclusions Policies and strategies to promote breastfeeding should include measures to identify and mitigate IPV against pregnant and breastfeeding women and provide optimal psychological and breastfeeding support for those who are victims of IPV.

Background. External validation of a vaginal birth after cesarean delivery (VBAC) prediction model is important before implementation in other settings. The primary aim of this study is to validate the Grobman prenatal VBAC calculator in the Ethiopian setting. Secondarily, the study was aimed at developing and comparing a new VBAC model that includes both the prenatal and intrapartum variables. Methods. A cross-sectional survey was conducted, complemented by a medical chart review of 268 women admitted at three teaching hospitals of Addis Ababa University and who underwent a trial of labor after one prior cesarean birth. Maternal age, prepregnancy BMI, prior vaginal delivery, prior VBAC, and prior cesarean delivery indication type were included in the Grobman model. Observed delivery outcomes were recorded and then compared with the outcomes predicted by the calculator. We assessed the predictive abilities of the Grobman model and the new model using a receiver operating characteristic (ROC) curve. Multivariate logistic regression analysis was conducted to identify variables associated with successful VBAC. Results. Out of the 268 participants, 186 (69.4%) (95% CI 57.5-81.3) had successful VBAC. The area under the ROC curve (AUC) of the Grobman model was 0.75 (95% CI 0.69-0.81). Notably, the novel model including both the prenatal and intrapartum variables had a better predictive value than the original model, with an AUC of 0.87 (95% CI 0.81-0.93). Prior VBAC, prepregnancy BMI, fetal membrane status, and fetal station at admission were predictors of VBAC in the newly developed logistic regression model. Conclusions. The success rate of VBAC was similar to other sub-Saharan African countries. The Grobman model performed adequately in the study setting; however, the model including both the prenatal and intrapartum variables was more predictive. Thus, intrapartum predictors used in the new model should be considered during intrapartum counseling.

ObjectivesThere is a lack of evidence on approaches to mitigating mistreatment during facility-based childbirth. This study compares the experiences of mistreatment reported by childbearing women before and after implementation of a respectful maternity care intervention.DesignA pre–post study design was undertaken to quantify changes in women’s experiences of mistreatment during facility-based childbirth before and after the respectful maternity care intervention.InterventionA respectful maternity care intervention was implemented in three hospitals in southern Ethiopia between December 2017 and September 2018 and it included training of service providers, placement of wall posters in labour rooms and post-training supportive visits for quality improvement.Outcome measuresA 25-item questionnaire asking women about mistreatment experiences was administered to 388 women (198 in the pre-intervention, 190 in the post-intervention). The outcome variable was the number of mistreatment components experienced by women, expressed as a score out of 25. Multilevel mixed-effects Poisson modelling was used to assess the change in mistreatment score from pre-intervention to post-intervention periods.ResultsThe number of mistreatment components experienced by women was reduced by 18% when the post-intervention group was compared with the pre-intervention group (adjusted regression coefficient (Aβ)=0.82, 95% CI 0.74 to 0.91). Women who had a complication during pregnancy (Aβ=1.17, 95% CI 1.01 to 1.34) and childbirth (Aβ=1.16, 95% CI 1.03 to 1.32) experienced a greater number of mistreatment components. On the other hand, women who gave birth by caesarean birth after trial of vaginal birth (Aβ=0.76, 95% CI 0.63 to 0.92) and caesarean birth without trial of vaginal birth (Aβ=0.68, 95% CI 0.47 to 0.98) experienced a lesser number of mistreatment components compared with those who had vaginal birth.ConclusionsWomen reported significantly fewer mistreatment experiences during childbirth following implementation of the intervention. Given the variety of factors that lead to mistreatment in health facilities, interventions designed to mitigate mistreatment need to involve structural changes.

Introduction:preventable mortality from complications which arise during pregnancy and childbirth continue to claim more than a quarter of million women's lives every year, almost all in low- and middle-income countries. However, life-saving emergency obstetric services, including caesarean section (CS), significantly contribute to the prevention of maternal and newborn mortality and morbidity. Between 2009 and 2013, a task shifting intervention to train caesarean section (CS) teams involving 41 CS surgeons, 35 anesthetic nurses and 36 scrub nurses was implemented in 13 hospitals in southern Ethiopia. We report on the attrition rate of those upskilled to provide CS with a focus on the medium-term outcomes and the challenges encountered. Methods:a cross-sectional study involving surveys of focal persons and a facility staff audit supplemented with a review of secondary data was conducted in thirteen hospitals. Mean differences were computed to appreciate the difference between numbers of CSs conducted for the six months before and after task shifting commenced. Results:from the trained 112 professionals, only 52 (46.4%) were available for carrying out CS in the hospitals. CS surgeons (65.9%) and nurse anesthetists (71.4%) are more likely to have left as compared to scrub nurses (22.2%). Despite the loss of trained staff, there was an increase in the number of CSs performed after the task shifting (mean difference=43.8; 95% CI:18.3-69.4; p=0.003). Conclusion:our study, one of the first to assess the medium-term effects of task shifting highlights the risk of ongoing attrition of well-trained staff and the need to reassess strategies for staff retention.

ObjectivesUptake of maternal health services remains suboptimal in Ethiopia. Significant proportions of antenatal care attendees give birth at home. This study was conducted to identify the predictors of non-institutional delivery among women who received antenatal care in the Southern Nations Nationalities and Peoples Region, Ethiopia.DesignA community-based cross-sectional survey was conducted among women who delivered in the year preceding the survey and who had at least one antenatal visit. Multistage cluster sampling was deployed to select 2390 women from all administrative zones of the region. A mixed-effects multivariable logistic regression analysis was performed to assess the predictors of non-institutional delivery; adjusted ORs (AOR) with 95% CIs are reported.ResultsThe proportion of non-institutional deliveries among participants was 62.2% (95% CI 60.2% to 64.2%). Previous experience of short and simple labour (46.9%) and uncomplicated home birth (42.9%), night-time labour (29.7%), absence of pregnancy-related problem (18.8%) and perceived providers poor reception of women (17.8%) were the main reasons to have non-institutional delivery. Attending secondary school and above (AOR=0.51; 95% CI 0.30 to 0.85), being a government employee (AOR=0.27; 95% CI 0.10 to 0.78) and woman’s autonomy in healthcare utilisation decision making (AOR=0.51; 95% CI 0.33 to 0.79) were among the independent predictors negatively associated with non-institutional delivery. On the other hand, unplanned pregnancy (AOR=1.67; 95% CI 1.16 to 2.42), not experiencing any health problem during pregnancy (AOR=8.1; 95% CI 3.12 to 24.62), not perceiving the risks associated with home delivery (AOR=6.64; 95% CI 4.35 to 10.14) were the independent predictors positively associated with non-institutional delivery.ConclusionsThere is a missed opportunity among women attending antenatal care in southern Ethiopia. Further health system innovations that help to bridge the gap between antenatal care attendance and institutional delivery are highly recommended.

IntroductionKangaroo Mother Care (KMC) is the practice of early, continuous and prolonged skin-to-skin contact between the mother and the baby with exclusive breastfeeding. Despite clear evidence of impact in improving survival and health outcomes among low birth weight infants, KMC coverage has remained low and implementation has been limited. Consequently, only a small fraction of newborns that could benefit from KMC receive it.Methods and analysisThis implementation research project aims to develop and evaluate district-level models for scaling up KMC in India and Ethiopia that can achieve high population coverage. The project includes formative research to identify barriers and contextual factors that affect implementation and utilisation of KMC and design scalable models to deliver KMC across the facility-community continuum. This will be followed by implementation and evaluation of these models in routine care settings, in an iterative fashion, with the aim of reaching a successful model for wider district, state and national-level scale-up. Implementation actions would happen at three levels: ‘pre-KMC facility’—to maximise the number of newborns getting to a facility that provides KMC; ‘KMC facility’—for initiation and maintenance of KMC; and ‘post-KMC facility’—for continuation of KMC at home. Stable infants with birth weightEthics and disseminationEthics approval was obtained in all the project sites, and centrally by the Research Ethics Review Committee at the WHO. Results of the project will be submitted to a peer-reviewed journal for publication, in addition to national and global level dissemination.Study statusWHO approved protocol: V.4—12 May 2016—Protocol ID: ERC 2716. Study implementation beginning: April 2017. Study end: expected March 2019.Trial registration numberCommunity Empowerment Laboratory, Uttar Pradesh, India (NCT12286667); St John's National Academy of Health Sciences, Bangalore, India and Karnataka Health Promotion Trust, Bangalore, India (CTRI/2017/07/008988); Society for Applied Studies, Delhi (NCT03098069); Oromia, Ethiopia (NCT03419416); Amhara, SNNPR and Tigray, Ethiopia (NCT03506698).

ObjectivesEven though surgical informed consent (SIC) has marked benefits, in many settings the information is not provided appropriately. In Ethiopia, minimal attention is given to SIC. This study assesses whether an intervention designed to improve SIC in obstetric and gynaecologic surgeries is associated with receipt of SIC components.DesignPre-intervention and post-intervention surveys were conducted at Hawassa University Comprehensive Specialized Hospital among women who underwent obstetric or gynaecologic surgeries. The intervention consisted of a 3-day training on standard counselling for surgical procedures offered to health professionals. A total of 457 women were surveyed (230 pre-intervention, 227 post-intervention). An adjusted Poisson regression analysis was used to identify the association between the intervention and the number of SIC components received.ResultsThe majority of participants were 25–34 years of age in both the pre-intervention and post-intervention groups (p=0.66). 45.7% of the pre-intervention and 51.5% of the post-intervention survey participants underwent elective surgery (p=0.21). Additionally, 70.4% of pre-intervention survey participants received counselling immediately before surgery, compared with 62.4% of post-intervention participants (pConclusionTraining on the delivery of standard SIC is associated with receipt of a higher number of standard counselling components. However, there is a need to evaluate whether a one-time intervention leads to sustained improvement. A system-wide study of factors that promote SIC is required.

Background 118 000 newborn babies in Ethiopia die each year and 500 000 pregnancy-related complications occur. Maternal mortality in Ethiopia is also very high (676 deaths per 100 000 livebirths); only 34% of mothers receive antenatal care and 10% of births took place in health facilities in 2011. We identified factors contributing to low use of institutional delivery services in the Southern Nations, Nationalities, and People's Region, Ethiopia. Methods We interviewed mothers who had given birth within the past year and organised six focus group discussions. We selected participants by multistage sampling proportional to the number of expected pregnancies in the 19 administrative zones in the region. We did univariate, bivariate, and multivariate analyses to assess 24 potential predictors of non-institutional delivery. We analysed focus group discussions with NVivo (version 10). Findings We interviewed 502 women from urban areas, 164 from rural pastoral areas, and 2231 from rural agrarian areas. 876 of 2897 (30·2%) births occurred in health institutions—412 of 502 (82·1%) births in urban areas, seven of 164 (4·3%) in rural pastoral areas, and 457 of 2231 (20·5%) in rural agrarian areas. Factors associated with non-institutional delivery include mother's education status (none vs grade 9 or higher: adjusted odds ratio [AOR] 3·91, 95% CI 2·76–5·56), mother's partner's educational status (primary vs none: AOR 0·65, 95% CI 0·49–0·86), occupation (merchant vs farmer: AOR 0·56, 95% CI 0·36–0·87), household financial decision-maker (male partner vs mother: AOR 2·12, 95% CI 1·52–2·95), monthly income ( vs ≥700 birr: AOR 1·77, 95% CI 1·43–2·18), use of antenatal clinic services (no use vs use: AOR 5·63, 95% CI 3·76–8·43), and knowledge of danger signs during delivery (don't know vs do know: AOR 2·16, 95% CI 1·83–2·55). Mothers with no education and who were aged younger than 18 years at their first marriage were more likely to give birth outside of a health institution compared with mothers who were educated to grade 9 or higher (AOR 3·91, 95% CI 2·76–5·56) and mothers who were aged 18 years and older at their first marriage (crude odds ratio 1·69, 95% CI 1·43–1·99). Mothers who planned their last pregnancy were less likely to give birth outside of a health institution compared with mothers who did not plan (AOR 0·48, 95% CI 0·37–0·63). Interpretation Institutional delivery is still uncommon in the Southern Nations, Nationalities, and People's Region despite several interventions. Innovative approaches are needed to attract women to health facilities. Funding Save the Children International.