Essential maternal health service disruptions in Ethiopia during COVID 19 pandemic: a systematic review

COVID 19 pandemic has challenged the resilience of the most effective health systems in the world. The Ethiopian Ministry of health tried to ensure the continuation of essential maternal health services during the pandemic. Despite several individual studies conducted on the impact of COVID 19 on maternal health services, no evidence can summarize the extent of impact as a nation and which essential maternal health service is most affected.

A systematic review was conducted to summarize the extent of disruption of essential maternal health services and identify the most affected service in the era of the COVID pandemic in Ethiopia. Preferred Reporting Items for Systematic Review and Meta-analysis guidelines were followed. Comprehensive literature was searched using international databases PubMed, Google scholar, and African Online Journal to retrieve related articles. Descriptive analysis was made to answer the review objective.

Overall, 498 articles were retrieved using our search strategy and finally 8 articles were included in the review. We found, ANC (26.35%), skilled birth attendance (23.46%), PNC (30%), family planning (14%), and abortion care (23.7%) maximum disruption of service utilization due to the pandemic. PNC service was the most significantly affected service unit followed by the ANC unit.

Essential maternal health services have been significantly disrupted due to COVID 19 pandemic in Ethiopia. It is expected from all stakeholders to prioritize safe and accessible maternity care during the pandemic and the aftermath and take lesson to reduce maternal and infant morbidity and mortality.

Ethiopia’s first minimally invasive surgery program: a novel approach in global surgical education

Complex lung diseases are among the leading causes of death in Ethiopia. Access to thoracic surgery is limited and prior to 2016 no thoracic surgeons were trained in minimally invasive surgery (MIS). A global academic partnership was formed between the University of Toronto and Addis Ababa University (AAU). Here, we describe implementation of the first MIS training program in sub-Sahara Africa and evaluate its safety.
Retrospective cohort analysis of open versus minimally invasive thoracic and upper gastrointestinal procedures performed at AAU from January 2016, to June 2021. Baseline demographic, diagnostic, operative, and post-operative outcomes including length of stay (LOS) and complications were compared.
In our bilateral model of surgical education, training is provided in Ethiopia and Canada over two years with focus on capacity building through egalitarian forms of knowledge exchange. Program features included certification in Fundamentals of Laparoscopic Surgery®, high-fidelity lobectomy simulation and hands on training. Overall, 41 open and 56 MIS cases were included in final statistical analysis. The average LOS in the MIS group was 5.2 days versus 11.0 days in the open group (p-value <0.001). The overall complication rate was 18% in the MIS group versus 39% open (p-value 0.020).
Here we demonstrated the successful initiation of sub-Sahara Africa’s first MIS program in thoracic and upper gastrointestinal surgery and characterize its patient safety. We envision the MIS program as a template to continue expanding global partnerships and improving surgical care in other resource-limited settings.

Bridging the know-do gap in low-income surgical environments: Creating contextually appropriate training videos to promote safer surgery in Ethiopia

Although international guidelines exist for the prevention of surgical site infections, their implementation in diverse clinical contexts, especially in low and middle-income countries, is challenging due to the lack of available resources and organizational structure of facilities. The goal of this project was to develop a series of video training aids to highlight best practices in surgical infection prevention in hospitals with limited resources and to provide practical solutions to common challenges faced in these settings.

Using the validated Clean Cut education framework for infection prevention developed by Lifebox, a charity devoted to improving surgical and anesthetic safety, we partnered with clinicians in one Ethiopian hospital to create six educational videos giving practical guidelines for infection prevention under resource variable conditions. These include: 1) proper use of the WHO Surgical Safety Checklist, 2) hand and skin antisepsis, 3) confirming instrument sterility, 4) maintaining the sterile field, 5) antibiotic prophylaxis, and 6) gauze counting.

Gaps in available online educational materials were identified in each of the six areas. Videos were created providing setting-specific education and addressing gaps in existing materials for each of the infection prevention topics. These videos are now integrated into infection prevention curricula through Lifebox in Ethiopia and ongoing data collection to evaluate acceptability and efficacy is ongoing.

Surgical education videos on infection prevention topics addressing location-specific resources and workarounds can be useful to hospitals operating in resource-limited settings for training staff and supporting quality and safety efforts in surgery.

Risk factors associated with acute kidney injury in a pediatric intensive care unit in Addis Ababa, Ethiopia. Case control study

Background: Acute kidney injury (AKI) is a serious problem in critically ill children. It is associated with poor treatment outcomes and a high rate of morbidity and mortality. Globally, one in three critically ill admitted children suffer from acute kidney injury. However, limited data are available in Africa, particularly in Ethiopia, highlighting the risk factors related to acute kidney injury. Therefore, this study aimed to identify the risk factors associated with acute kidney injury among critically ill children admitted to the pediatric intensive care unit at the Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia.

Methods: A facility-based unmatched case-control study was carried out on 253 (85 cases and 168 controls) children admitted to the pediatric intensive care unit from January 2011 to December 2021. Participants were selected using a systematic random sampling technique for the control group and all cases consecutively. Data were collected using a structured checklist. Data were entered using Epi data version 4.6 and analyzed using SPSS version 25. Multivariate analysis was carried out using the adjusted odds ratio (AOR) with a 95% confidence interval (CI) to identify associated factors with acute kidney injury. Statistical significance was set at P < 0.05.

Results: The median age of the participants was two years. About 55.6 % of cases and 53.1% of controls were females. The diagnosis of hypertension (AOR= 5.36; 95% CI: 2.06- 13.93)], shock (AOR=3.88, 95% CI: 1.85- 8.12), exposure to nephrotoxic drugs (AOR=4.09; 95% CI: 1. 45- 11.59), sepsis or infection AOR=3.36; 95% CI: 1.42-7.99), nephritic syndrome (AOR=2.97; 95% CI :1.19, 7.43), and mechanical ventilation AOR=2.25, 95% CI: 1.12, 4.51) were significantly associated with acute kidney injury.

Conclusion: In this study, the diagnosis of sepsis or infection, hypertension, shock, nephrotoxic drugs, demand for mechanical ventilation support, and nephritic syndrome increased the risk of AKI among critically ill children. Multiple risk factors for AKI are associated with illness and its severity. All measures that ensure adequate renal perfusion must be taken in children with identified risk factors to avoid the development of AKI.

Patient-Reported Outcome Measures for Acetabular Fractures Treated Operatively without a C-Arm in Ethiopia

There is little evidence describing the open treatment of displaced acetabular fractures in low-resource environments. We endeavored to determine the results of the operative management of acetabular fractures without intraoperative C-arm use in a developing nation, through the assessment of patient-reported outcome measures.

This was a prospective, single-surgeon, consecutive case series conducted in a tertiary referral hospital in Ethiopia, a high-population, low-income country. The primary author performed fixation without the use of a C-arm in 108 patients from among a total of 202 patients presenting with acetabular fracture. The modified Harris hip score (mHHS) and Short-Form Health Survey (SF)-36 at a minimum of 2 years postoperatively were used to assess the outcome.

Of the 108 patients potentially available for analysis, 92 (85%) were available for 2-year follow-up (mean age of 35 years; range, 15 to 70 years). The mean duration from injury to surgery was 16 days (range, 1 to 204 days). Seventy-three (78.5%; n = 93) of the patients had associated fracture patterns. The most common fractures were associated both-column type (22%) and transverse-plus-posterior-wall type (22%). The mean mHHS was 91; 88% of the patients had a score of ≥80, and 12% had a score of ≤79. SF-36 scores were in alignment with the mHHS. The majority (approximately 90%) of our cohort returned to work. We did not find a significant difference in the mean mHHS between patients with or without anatomic reduction (p = 0.31). However, 2-year radiographic outcomes were strongly associated with the mean mHHS (p < 0.001). Predictors of a lower mHHS included older age, cartilage damage, and lack of secondary congruence. Conclusions: Good functional outcomes were achieved at 2 years among patients with acetabular fractures surgically treated without the use of a C-arm in a limited-resource setting. Surgical congruence of the femoral head under the acetabular roof, rather than the absolute residual gap, seems essential in determining clinical outcomes. This information can help in planning increased access to care for individuals who experience traumatic injuries in low- and middle-income countries.

Implementing surgical mentorship in a resource-constrained context: a mixed methods assessment of the experiences of mentees, mentors, and leaders, and lessons learned

A well-qualified workforce is critical to effective functioning of health systems and populations; however, skill gaps present a challenge in low-resource settings. While an emerging body of evidence suggests that mentorship can improve quality, access, and systems in African health settings by building the capacity of health providers, less is known about its implementation in surgery. We studied a novel surgical mentorship intervention as part of a safe surgery intervention (Safe Surgery 2020) in five rural Ethiopian facilities to understand factors affecting implementation of surgical mentorship in resource–constrained settings.

We designed a convergent mixed-methods study to understand the experiences of mentees, mentors, hospital leaders, and external stakeholders with the mentorship intervention. Quantitative data was collected through a survey (n = 25) and qualitative data through in-depth interviews (n = 26) in 2018 to gather information on (1) intervention characteristics including areas of mentorship, mentee-mentor relationships, and mentor characteristics, (2) organizational context including facilitators and barriers to implementation, (3) perceived impact, and (4) respondent characteristics. We analyzed the quantitative and qualitative data using frequency analysis and the constant comparison method, respectively; we integrated findings to identify themes.

All mentees (100%) experienced the intervention as positive. Participants perceived impact as: safer and more frequent surgical procedures, collegial bonds between mentees and mentors, empowerment among mentees, and a culture of continuous learning. Over 70% of all mentees reported their confidence and job satisfaction increased. Supportive intervention characteristics included a systems focus, psychologically safe mentee-mentor relationships, and mentor characteristics including generosity with time and knowledge, understanding of local context, and interpersonal skills. Supportive organizational context included a receptive implementation climate. Intervention challenges included insufficient clinical training, inadequate mentor support, and inadequate dose. Organizational context challenges included resource constraints and a lack of common understanding of the intervention.

We offer lessons for intervention designers, policy makers, and practitioners about optimizing surgical mentorship interventions in resource-constrained settings. We attribute the intervention’s success to its holistic approach, a receptive climate, and effective mentee-mentor relationships. These qualities, along with policy support and adapting the intervention through user feedback are important for successful implementation.

Virtual reality technology in linked orthopaedic training in Ethiopia

We describe the feasibility of delivering a live orthopaedic surgical teaching session with virtual reality (VR) technology simultaneously for trainee surgeons in Ethiopia and the UK.

Forty-three delegates from the Severn Deanery in the UK (n=30) and Bahir Dar in Ethiopia (n=13) attended a live training session in February 2021. During the session, participants watched a surgical operation (recorded earlier that week with a 360° VR camera) alongside live commentary. A qualitative questionnaire was distributed to gauge feasibility, connectivity and educational value of the session as well as its VR component.

The majority of delegates from both the UK and Ethiopia felt that the use of VR technology to aid surgical training is feasible, that it is useful for learning surgical approaches, that it aids surgical performance and that it is superior to conventional resources. Bahir Dar residents strongly agreed that VR simulation videos would allow trainees to supplement reduced learning opportunities as a result of the COVID-19 pandemic and help to counteract their reduced operating experience. For Bahir Dar trainees, a lack of a stable internet connection for large VR files was the predominant issue.

This study demonstrates that there are infrastructure challenges in low and middle income countries (LMICs) in terms of the reliable delivery of VR teaching in orthopaedics at the current time. Despite this, our findings better inform the potential role of VR technology in surgical education, and shed light on the possibility for it to feed into and enrich surgical training in both LMICs and high income countries.

The magnitude and perceived reasons for childhood cancer treatment abandonment in Ethiopia: from health care providers’ perspective

Treatment abandonment is one of major reasons for childhood cancer treatment failure and low survival rate in low- and middle-income countries. Ethiopia plans to reduce abandonment rate by 60% (2019–2023), but baseline data and information about the contextual risk factors that influence treatment abandonment are scarce.

This cross-sectional study was conducted from September 5 to 22, 2021, on the three major pediatric oncology centers in Ethiopia. Data on the incidence and reasons for treatment abandonment were obtained from healthcare professionals. We were unable to obtain data about the patients’ or guardians’ perspective because the information available in the cancer registry was incomplete to contact adequate number of respondents. We used a validated, semi-structured questionnaire developed by the International Society of Pediatric Oncology Abandonment Technical Working Group. We included all (N = 38) health care professionals (physicians, nurses, and social workers) working at these centers who had more than one year of experience in childhood cancer service provision (a universal sampling and 100% response rate).

The perceived mean abandonment rate in Ethiopia is 34% (SE 2.5%). The risk of treatment abandonment is dependent on the type of cancer (high for bone sarcoma and brain tumor), the phase of treatment and treatment outcome. The highest risk is during maintenance and treatment failure or relapse for acute lymphoblastic leukemia, and during pre- or post-surgical phase for Wilms tumor and bone sarcoma. The major influencing risk factors in Ethiopia includes high cost of care, low economic status, long travel time to treatment centers, long waiting time, belief in the incurability of cancer and poor public awareness about childhood cancer.

The perceived abandonment rate in Ethiopia is high, and the risk of abandonment varies according to the type of cancer, phase of treatment or treatment outcome. Therefore, mitigation strategies to reduce the abandonment rate should include identifying specific risk factors and prioritizing strategies based on their level of influence, effectiveness, feasibility, and affordability.

Patterns of injuries among Children visiting Gondar town public health institutes, Northwest Ethiopia, 2019

Background: Injuries have been recognized as the leading cause of death in children for nearly 40 years. However, most epidemiological studies of injuries have not been community-based and are limited either to a single type of injury, such as head injuries or burnsor to a specific cause of injury, such as consumer products.

Objective: To determine patterns of injuries among children visiting Gondar town public health institutes, Northwest Ethiopia,2019.

Methods: An institutional-based prospective cross-sectional study was conductedamong children visiting Gondar town public health institutes of Amhara region, Northwest Ethiopia from June 25 to September 25, 2019. A total of 385 participants were included in the study. Data were entered into Epi-info version 7.2.1 and exported to SPSS version 21.0 for analysis and descriptive statistics were presented in text, tables, charts, and graphs.

Result: The majority of the pediatric trauma cases were seen in males 61.8%, (n = 238) and females comprised only 38.2% (n = 147). Stone or stick injury (29.1%) was the most common mode of trauma followed by road traffic injuries (21.0%), falls (19.0%), and burns (14.0%). The majority of injuries happened during playing (53%) and around the home (37.9%). In this study the three top most frequent sites of injuries were: lower extremity injury 167 (43.4%), upper extremity127 (33.0%), and head injury 50 (13.0%).

Conclusion and recommendation: The high rate of pediatric trauma from sticks or stones, roadways, and falls highlights the need for increased supervision and identification of specific dangers when playing. In our scenario, a comprehensive trauma registry appears to be critical for developing policies to lessen the burden of pediatric trauma. Further research with large sample size and associated factors for pediatric injuries is recommended.

Compliance with the World Health Organization’s surgical safety checklist and related postoperative outcomes: a nationwide survey among 172 health facilities in Ethiopia

Ministry of Health (MOH) of Ethiopia adopted World Health Organization’s evidence-proven surgical safety checklist (SSC) to reduce the occurrence of surgical complications, i.e., death, disability and prolong hospitalization. MOH commissioned this evaluation to learn about SSC completeness and compliance, and its effect on magnitude of surgical complications.

Health institution-based cross-sectional study with retrospective surgical chart audit was used to evaluate SSC utilization in 172 public and private health facilities in Ethiopia, December 2020–May 2021. A total of 1720 major emergency and elective surgeries in 172 (140 public and 32 private) facilities were recruited for chart review by an experienced team of surgical clinicians. A pre-tested tool was used to abstract data from patient charts and national database. Analyzed descriptive, univariable and bivariable data using Stata version-15 statistical software.

In 172 public and private health facilities across Ethiopia, 1603 of 1720 (93.2%) patient charts were audited; representations of public and private facilities were 81.4% (n = 140) and 18.6% (n = 32), respectively. Of surgeries that utilized SSC (67.6%, 1083 of 1603), the proportion of SSC that were filled completely and correctly were 60.8% (659 of 1083). Surgeries compliant to SSC guide achieved a statistically significant reduction in perioperative mortality (P = 0.002) and anesthesia adverse events (P = 0.005), but not in Surgical Site Infection (P = 0.086). Non-compliant surgeries neither utilized SSC nor completed the SSC correctly, 58.9% (944 of 1603).

Surgeries that adhered to the SSC achieved a statistically significant reduction in perioperative complications, including mortality. Disappointingly, a significant number of surgeries (58.9%) failed to adhere to SSC, a missed opportunity for reducing complications.