Health education has improved mothers’ knowledge of obstetric danger signs and birth preparedness and complication readiness practices in southern Ethiopia: A cluster randomised controlled trial.
Amanuel Yoseph 1*, Wondwosen Teklesilasie 1, Francisco Guillen-Grima2, Ayalew Astatkie 1
1 School of Public Health, College of Medicine and Health Sciences, Hawassa University, Hawassa, Ethiopia. 2. Department of Health Sciences, Public University of Navarra, Pamplona, Spain.
Introduction: Increasing knowledge of obstetric danger signs (ODS) and encouraging birth preparedness and complication readiness (BPCR) practices are strategies to increase skilled maternal health service utilisation in low-income countries. One of the methods to increase mothers’ knowledge about ODS and promote BPCR practice is through health education intervention (HEI). However, the effect of health education on these outcomes has yet to be comprehensively studied, and the existing evidence is inconclusive. Thus, we aimed to assess HEI’s effect on mothers’ knowledge regarding ODS and BPCR practices in southern Ethiopia.
Methods: An open-label, two-arm parallel group cluster-randomized controlled trial was conducted from January to August 2023 on pregnant women from 24 clusters (12 interventions and 12 controls) in the northern zone of the Sidama region. The Open Data Kit smartphone application was utilised to collect and export data for analysis to SPSS version 26 and Stata version 17. The intention-to-treat analysis was used to compare outcomes between groups. The independent sample test was used to compare the effects of the intervention between two groups in an unadjusted analysis. We fitted multi-level mixed-effect negative binomial regression to account for between and with cluster effects. Using the Bonferroni correction methods, the statistical significance level was adjusted to account for the effects of multiple comparison problems.
Results: 1,070 pregnant women (540 and 530 from intervention and control clusters) responded to this study, making the overall response rate 95.02%. Excessive vaginal bleeding (94.3% in the interventional group vs. 88.7% in the control group) was the commonest ODS mentioned during childbirth. Saving money and materials (97.1% in the interventional group vs. 92.7% in the control group) was the most frequently mentioned BPCR practice. A HEI had significantly increased ODS knowledge (adjusted incidence rate ratio [AIRR]: 1.51; 95% CI: 1.29-1.77) and improved BPCR practice (AIRR: 1.51; 95% CI: 1.16-1.96). The identified determinants of ODS knowledge were women’s mass media use (AIRR = 1.17; 95% CI: 1.09-1.25) and receiving model family training (AIRR = 1.07; 95% CI: 1.01-1.13). BPCR practice was associated with women’s mass media use (AIRR = 1.37; 95% CI: 1.19-1.57) and receiving model family training (AIRR = 1.16; 95% CI: 1.03-1.30).
Conclusions: A community-based HEI improved mothers’ knowledge regarding ODS and BPCR practices in rural settings. Any intervention approach must implement community-based HEI to increase women’s knowledge of ODS and improve BPCR practice, which aligns with World Health Organization recommendations.
Trial registration: NCT05865873
Keywords: Health education, obstetric danger signs, birth preparedness, complications readiness plan, women of reproductive age, cluster randomised controlled trial, multi-level mixed effect negative binomial regression, Bonferroni corrections methods, Ethiopia.
Reliability and validity of the Sidaamu Afoo version of the Pelvic Organ Prolapse Symptom Score questionnaire
Melese Siyoum, Wondwosen Teklesilasie, Rahel Nardos, Biniyam Sirak, Ayalew Astatkie
Hawassa University
Background: Both for clinical and research purposes, it is critical that clinicians and researchers use a tool that is trans-culturally adapted and tested for its psychometric properties. The English version of the Pelvic Organ Prolapse Symptom Score (POP-SS) questionnaire was developed in 2000. Since then, it has been translated into other languages and verified. However, the tool has yet to be adapted to the Sidaamu Afoo language. This study aimed to translate and adapt the Pelvic Organ Prolapse Symptom Score questionnaire into Sidaamu Afoo and evaluate its psychometric properties.
Methods: 100 women with symptomatic prolapse completed version 2 of the POP-SS questionnaire during the first round of interviews, and 61 completed the questionnaire during the second round (to establish the test-retest reliability). The content validity was assessed using the content validity index, and the construct validity was done based on exploratory factor analysis using the principal component analysis model. The criterion validity was evaluated using the Kruskal-Wallis test based on stages of the prolapse established via pelvic examination. The internal consistency reliability of the scale was assessed using Cronbach’s alpha value, and test-retest reliability was evaluated using the intraclass correlation coefficient.
Results: The questionnaire was successfully translated to Sidaamu Afoo and achieved a good content validity index (0.88), high internal consistency (Cronbach’s alpha of 0.79), and test-retest reliability (an intraclass correlation coefficient of 0.83). The exploratory factor analysis revealed two factors based on an eigenvalue of 1. The two factors explained 70.6% of the common variance, and each item loaded well (0.61 to 0.92) to its corresponding factor. There is a significant difference in the median score of prolapse symptoms across different stages of prolapse (Kruskal-Wallis c2, 17.5, p < 0.001).
Conclusion: The Sidaamu Afoo version of the POP-SS tool is valid and reliable. Further studies that involve a balanced number of women in each prolapse stage are needed to avoid the ceiling and floor effects.
The Roles of the Health Extension Program in reducing Maternal and child mortality in Ethiopia from 1990 to 2019: An interrupted Time Series Analysis
Mekdes Yilma1, Tegene Dadi2,3, Habtamu Kasaye4, Girmay Medhin5,3, Mulusew Jebena6
1Department of Public Health, Institute of Health Sciences, Wollega University, Ethiopia 2School of Public Health, Hawassa University, Ethiopia 3MERQ Consultancy PLC, Addis Ababa, Ethiopia 4Department of Midwifery, Institute of Health Sciences, Wollega University, Ethiopia 5Aklilu Lemma Institute of Pathobiology, Addis Ababa University, Ethiopia 6 Department of Epidemiology, Faculty of Public Health, Jimma University
Background: The Ethiopian Health Extension Program has operated for nearly two decades to address basic challenges in healthcare services. While some reports suggest its effectiveness in specific maternity care interventions, there is limited empirical evidence regarding its impact on maternal and child mortality trends. Hence, this study aims to explore the role of the Ethiopian Health Extension Program in reducing maternal, neonatal, and under-five child mortality.
Methods: We conducted a longitudinal ecological study by utilising successive reports from the Ethiopian Demographic and Health Survey, the annual reports from the Ministry of Health, and the World Health Organization’s mortality database. We conducted an interrupted time-series analysis employing a linear segmented regression model to model the program’s effect. Overall, we utilised 30 time points, with 13 preceding the program’s implementation (1990–2003), eight within the implementation period (2003-2010), and nine following the program’s full implementation.
Results: Before the initial implementation of the Health Extension Program, there was a declining trend in maternal mortality ratio (MMR) by 51.2 [95% CI: -60.2, -42.3], under-five mortality (U5MR) by 4.6 (95% CI: -8.4, -0.7), and neonatal mortality rate (NMR) by 1.6 (95% CI: -2.3, -0.9). However, there was a significant increase in maternal mortality ratio levels during the implementation period from 2003 to 2006. In 2010, the post-implementation linear trends for MMR, U5MR, and NMR exhibited significant reductions by 38.7 (95% CI: -52.4, -25.0), 4.4 (95% CI: -8.4, -0.3), and 0.9 (95% CI: -1.3, -0.6), respectively.
Conclusion: The Ethiopian Health Extension Program has substantially lowered maternal and child mortality rates. The evidence from existing data underscores the program’s importance and emphasises the need for consistent implementation nationwide and integration into other national healthcare strategies.
Keywords: maternal and child mortality, health extension program, interrupted time series analysis, segmented regression
Contraceptive use among reproductive-age females with disabilities in central Sidama National Regional State, Ethiopia: a multilevel analysis
Zelalem Tenaw , Taye Gari , Achamyelesh Gebretsadik
Hawassa University
Background: Contraceptive use is an essential, cost-effective intervention to prevent unwanted pregnancies. People with disabilities face discrimination when using contraception and are double burdened by unwanted pregnancies. However, the status of contraceptive use and associated factors among reproductive-aged females with disabilities was not determined adequately in Ethiopia.
Objective: This study aimed to assess contraceptive use and associated factors among reproductive-age females with disabilities in Dale and Wonsho districts and Yirgalem city administration of central Sidama National Regional State, Ethiopia.
Methods: A community-based cross-sectional study was conducted among randomly selected 620 reproductive-age females with disabilities living in the selected districts from June 20 to July 15, 2022. The data were collected through face-to-face interviewing techniques using a structured questionnaire. A multilevel logistic regression analysis model was employed to analyse the data. The adjusted odds ratio (AOR) with a 95% confidence interval (CI) was used to report the measures of associations.
Results: In this study, 27.3 % (95% CI: 23.8 %, 31.0 %) of the reproductive-age females with disabilities were current contraceptive users. Regarding the methods, 82 (48.5%) of the reproductive-age females with disabilities used implants. Having good contraceptive knowledge (AOR=9.03; 95% CI: 4.39, 18.6), transport accessibility to health facilities (AOR=2.28; 95% CI: 1.32, 3.94), being an adult (25 to 34 years old) (AOR=3.04; 95% CI: 1.53, 6.04), having a hearing disability (AOR = 0.38; 95% CI: 0.18, 0.79), paralysis of the extremities (AOR = 0.06; 95% CI: 0.03, 0.12) and wheel-chaired disability (AOR = 0.10; 95% CI: 0.05, 0.22) were factors associated with contraceptive use.
Conclusion: Contraceptive use among reproductive-age females with disabilities is low. Transport accessibility, contraceptive knowledge, being in the age groups of 25 to 34 years, and the types of disability determine their contraceptive use. Therefore, designing appropriate strategies to provide contraceptive education and information and provide contraceptive services in their homes is important to enhance contraceptive use.
Anopheles species diversity, blood meal sources and their role in malaria transmission in lowlands of Gamo Zone, South Ethiopia
Nigatu Eligo, Daniel Woldiyes, Bernt Lindtjørn, Fekadu Massebo
Department of Biology, Arba Minch University, Ethiopia,
Introduction: Understanding malaria mosquitoes’ blood-feeding behaviour and species composition is essential to planning and evaluating interventions effectively. Opportunistic feeding allows some mosquitoes to continue the residual transmission of malaria in communities. Therefore, the current study aimed to assess malaria mosquito species composition and blood meal sources as a baseline study of the randomised controlled trial, which aims to evaluate the effectiveness of improving housing conditions and treating cattle with ivermectin.
Methods: The mosquito samples were collected from houses randomly selected within clusters chosen for the trial, utilising Centers for Disease Control (CDC) light traps. The identification of all collected mosquito species and assessment of their abdominal condition were conducted and preserved within silica gel until laboratory analysis. An enzyme-linked immunosorbent assay (ELISA) was performed to detect circum-sporozoite proteins, whereas a polymerase chain reaction test was conducted to analyse blood meal sources.
Results: Nine species of Anopheles mosquitoes were found: Anopheles arabiensis, Anopheles dancalicus, Anopheles demeilloni, Anopheles garnhami, Anopheles pharoensis, Anopheles rhodesiensis, Anopheles salbaii, and Anopheles tenebrosus. Anopheles arabiensis was the primary malaria vector, exhibiting a 0.5% CSP infection rate. Two hundred forty-four mosquitoes were tested for blood meal sources. Among these, 26% (64 out of 244) had fed on goats, 5% (11 out of 244) on humans, 2% (5 out of 244) on dogs, and 2% (4 out of 244) on cows. Among 244 blood meals, 5% were mixed blood meals involving dogs and humans (13 out of 244), and 1% were goats and dogs. A triple blood meal of humans, goats, and dogs (1%; 2 out of 244) was also documented.
Conclusion: The feeding behaviour of Anopheles arabiensis suggests that they may be difficult to control with indoor-based interventions due to their wide range of blood meal sources from animal hosts.
Keywords: Blood meal source, Anopheles mosquito, Sporozoite infection, Species composition
Efficacy and safety of praziquantel treatment against Schistosoma mansoni infection among pre-school age children in southern Ethiopia
Tafese Tadele1, Ayalew Astatkie1, Birkneh Tilahun Tadesse2, Eyasu Makonnen3,4, Eleni Aklillu5,* and Solomon Mequanente Abay4
1School of Public Health, College of Medicine and Health Sciences, Hawassa University, Hawassa P.O. Box 1560, Ethiopia 2Department of Pediatrics, College of Medicine and Health Sciences, Hawassa University, Hawassa P.O. Box 1560, Ethiopia 3Center for Innovative Drug Development and Therapeutic Trials for Africa, College of Health Sciences, Addis Ababa University, Addis Ababa P.O. Box 9086, Ethiopia 4Department of Pharmacology and Clinical Pharmacy, College of Health Sciences, Addis Ababa University, Addis Ababa, P.O. Box 9086, Ethiopia 5Department of Global Public Health, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
* Correspondence: eleni.aklillu@ki.se (E.A)
Background: Preventive chemotherapy with a single dose of praziquantel given to an all-at-risk population through mass drug administration is the cornerstone intervention to control and eliminate schistosomiasis as a public health problem. This intervention mainly targets school-age children, and preschool-age children (pre-SAC) are excluded from receiving preventive chemotherapy, partly due to scarcity of data on praziquantel treatment outcomes.
Methods: We conducted active efficacy and safety surveillance of praziquantel treatment among 240 Schistosomamansoni-infected pre-SAC who received a single dose of praziquantel (40 mg/kg) in southern Ethiopia. The study outcomes were egg reduction rates (ERR) and cure rates (CRs) four weeks after treatment using the Kato-Katz technique and treatment-associated adverse events (AEs) that occurred within eight days post-treatment.
Results: The overall ERR was 93.3% (WHO reference threshold ≥ 90%), while the CR was 85.2% (95% CI = 80.0% – 89.5%). Baseline S. mansoni infection intensity was significantly associated with CRs, 100% among light infected than moderate (83.4%) or heavy (29.4%) infected children. An increase of 100 in baseline S. mansoni egg count per gram of stool resulted in a 26% (95% CI: 17%, 34%) reduction in the odds of cure. The incidence of experiencing at least one type of AE was 23.1% (95% CI: 18.0%, 29.0%). Stomachache, diarrhoea, and nausea were the most common AEs. AEs were mild-to-moderate grade and transient. Pre-treatment moderate (ARR = 3.2, 95% CI: 1.69, 6.14) or heavy infection intensity (ARR= 6.5, 95% CI: 3.62, 11.52) was a significant predictor of AEs (p < 0.001). Sex, age, or soil-transmitted helminth coinfections were not significant predictors of CR or AEs.
Conclusions: Single-dose praziquantel is tolerable and effective against S. mansoni infection among pre-SAC, and associated AEs are mostly mild-to-moderate and transient. However, the reduced CR in heavily infected and AEs in one-five of pre-SAC underscores the need for safety and efficacy monitoring, especially in moderate-to-high infection settings. Integrating pre-SACs in the national deworming programs is recommended to accelerate the elimination of schistosomiasis as a public health problem.
Keywords: Efficacy; Safety; Praziquantel; Pre-school age children; Schistosomiasis, Schistosoma mansoni; Cure rate; Egg reduction rate; Pharmacovigilance; Ethiopia
Therapeutic efficacy of artemether-lumefantrine in the treatment of uncomplicated Plasmodium falciparum malaria in Arba Minch area district, Gamo Zone, Southwest Ethiopia
Demeke Daka1,2, Daniel Woldeyes1, Lemu Golassa3, Gezahegn Solomon3, Zerihun Zewude4, Girum Tamiru1, Tadesse Misganawu5, Fekadu Massebo1, Biniam Wondale1
1Department of Biology, Arba Minch University, Ethiopia 2Department of Biology, Madda Walabu University, Bale Robe, Ethiopia 3Aklilu Lemma Institute of Pathobiology, Addis Ababa University, Ethiopia 4Arba Minch Branch Public Health Laboratory, Ethiopia 5Department of Medical Laboratory Science, Woldia University, Ethiopia
Introduction: The emergence of drug-resistant malaria parasites is a severe concern for the prevention and control of malaria. Since 2004, Artemether-lumefantrine (AL) has been Ethiopia’s primary drug for treating uncomplicated Plasmodium falciparum malaria. It is necessary to regularly monitor antimalarial drug resistance in areas where malaria is prevalent. Therefore, the objective of this study was to evaluate the effectiveness of AL in treating uncomplicated Plasmodium falciparum malaria in the Arba Minch area district in the Gamo Zone of Southwest Ethiopia.
Methods: A single-arm prospective study was conducted from July to October 2022, with a 28-day follow-up period. The study included patients aged 18 years and above who visited Ganta Sira Health Post for malaria diagnosis and tested positive for P. falciparum mono-infection. The study used a consecutive sampling technique until the required sample size was achieved. For each patient, socio-demographic and clinical data were recorded. PCR-confirmation of MSP-1 and MSP-2 genes was carried out only for recurrent cases to differentiate recrudescence from re-infection. The data was entered and analysed using the WHO Excel spreadsheet and SPSS version 26.
Results: Eighty-nine patients were enrolled, and 67 had completed the 28-day follow-up period. The AL treatment resulted in 100% fever clearance by day two and parasite clearance by day 3. Complete gametocyte clearance was observed on day 14. During the follow-up period, five participants experienced recurrent malaria, one on day 14 and four on day 21. Three were classified as recrudescent cases, while two were re-infections confirmed by the msp-1 and msp-2 genes. According to the Kaplan Meir survival analysis, the success rate was 93.7% (95% CI: 85.5-97.3) and 96.2% (95% CI: 85.5–98.7) for PCR-uncorrected and PCR-corrected cases.
Conclusion: AL was efficacious in treating uncomplicated P. falciparum malaria in the study area.
Keywords: Cure rate, parasite clearance, recrudescence, recurrent malaria, Ethiopia
Prevalence of intestinal protozoa parasites among children under five and calves in lowland of Gamo zone, Southern Ethiopia: a baseline study
Hailu Shibru, Biniam Wondale, Bernt Lindtjørn Teklu Wegayehu
Department of Biology, Arba Minch University, Arba Minch, Ethiopia
Background: Intestinal parasitic diseases caused by intestinal protozoan parasites are a major public health concern in developing countries such as Ethiopia. Children under five and calves are more susceptible to these infections. It is important to note that some of these parasites are zoonotic. This study aims to determine the prevalence of intestinal protozoan parasite infections in children and calves under five years old residing in the study area.
Methods: A community-based cross-sectional study was conducted from July to September 2023 in lowland Kebeles of the two districts in the Gamo Zone to document the baseline data for the large malaria trial. Faecal samples were collected from 326 children under five and 41 calves in five Kebeles of the study area. Formol-ethyl acetate sedimentation and modified acid-fast staining techniques were done to identify cysts, oocysts, and ova of intestinal parasites. The prevalence of intestinal parasites was described using descriptive statistics.
Results: The overall prevalence of intestinal protozoan infections in under-five children was 18% (58/326). The most common protozoan parasites found were Giardia lamblia (11%; 37/326), Cryptosporidium species (4%; 13/326), and Entamoeba histolytica/diasper (2.5%; 8/326). Only a few helminths were found, of which H. nana accounted for 1.5% (5/326) and Taenia species accounted for 0.3% (1/326). Additionally, Giardia lamblia and Entamoeba histolytica/diasperwere found in calves with a prevalence of 2.5% (1/41) each.
Conclusion: In the study setting, intestinal protozoa infections are common, highlighting the need for personal hygiene and environmental sanitation. Molecular studies should be conducted to identify cryptosporidium species.
Keywords/phrases: Calves, Intestinal protozoa parasites, Under-five children, Zoonosis
Co-administration of primaquine with chloroquine inhibited parasite transmission to mosquitoes in Plasmodium vivax mono-infected adults better than chloroquine alone in Ethiopia.
Mesay Melaku1,2, Biniam Wondale1, Bernt Lindtjørn1, Fekadu Massebo1
1Department of Biology, Arba Minch University, Ethiopia 2Department of Biology, Wolaita Sodo University, Ethiopia
Introduction: Primaquine is given with chloroquine to combat the liver stage and gametocytes of Plasmodium vivax. However, additional research is necessary to understand more about the effectiveness of these drugs in preventing parasite transmission to mosquitoes during the early days of post-treatment. This study aims to investigate the effects of combining primaquine with chloroquine in Plasmodium vivax patients, focusing on parasite transmission compared to chloroquine alone.
Methods: A randomised controlled trial with an open-label design was conducted to evaluate the additional benefit of primaquine on parasite transmission and clearance in individuals diagnosed with P. vivax mono-infection. The trial took place between February and June 2023 by recruiting cases from the health facilities in Arba Minch, Ethiopia. The primary endpoint was to determine the impact of parasite transmission on mosquitoes in the first three days. To do this, a membrane-feeding assay was conducted using colony Anopheles arabiensis at days 0, 24, and 72 hours post-treatment. Mosquitoes were dissected on day 8 to assess oocyst infection and, on day 12, tested for circumsporozoite protein to determine the drug’s effect on parasite transmission. The patients were monitored for 28 days to assess the parasite clearance rate using polymerase chain reaction (PCR).
Results: In this study, 64 patients were randomly assigned into two groups. However, eight patients were excluded from the study after PCR correction of the microscopy results. The study used 56 cases of P. vivax to test mosquito infectivity, but seven patients lost their follow-up after day three. Before treatment, 57% (16/28) of the patients in the chloroquine-only group and 79% (22/28) in the combination group were infectious to mosquitoes. However, after 24 hours of treatment, the percentage of infectious patients decreased to 36% (10/28) in the chloroquine-only group and 21% (6/28) in the combination group. The relative percentage reduction was 38% in the chloroquine-only group and 73% in the combination group. At 24 hours, the patients treated with chloroquine alone showed a mean reduction of 88% in oocyst density.
Meanwhile, the group treated with primaquine in combination with chloroquine showed a higher reduction of 97% compared to the baseline, but the difference was not statistically significant. After 72 hours of treatment, all patients in both groups were non-infectious to mosquitoes. The asexual parasites were cleared from the majority of patients within 72 hours after treatment, except for seven patients (five from the chloroquine-only group and two from the combination group). By day 7, all asexual parasites were cleared—no parasites were found until day 28.
Conclusion: The administration of primaquine and chloroquine further inhibits parasite transmission to mosquitoes but does not impact parasite clearance.
Keywords/phrases: Anopheles, Chloroquine, Plasmodium vivax, Parasite transmission, Primaquine
Low ownership and utilisation of insecticide-treated net in malaria-endemic districts in the lowlands of Gamo Zone, Southwest Ethiopia.
Feven Wudneh,1,2 Teklu Wegayehu,1 Daniel Woldeyes,1 Bernt Lindtjørn1
1Department of Biology, Arba Minch University, Arba Minch, Ethiopia 2Medical Laboratory Science, Dilla University, Ethiopia
Introduction: Effective malaria prevention and control heavily relies on using Insecticide-treated bed nets (ITNs) as the primary vector control tools. The effectiveness of ITNs depends on consistent utilisation and coverage. This study aims to provide vital information on bed net ownership and utilisation in malaria-endemic districts.
Methods: This is a baseline study of a cluster randomised control trial of house screening and ivermectin cattle treatment on spatiotemporal clustering of malaria and anaemia. The study was conducted between July and September 2023 and involved 940 households and 4063 household members selected from nine malaria-endemic Kebeles. To assess the association between LLINs utilisation and ownership and potential predictor variables, various statistical methods such as descriptive, univariate, bivariate, and multilevel logistic regressions were employed. The strength and statistical significance of the association were determined using the odds ratio (OR) and corresponding 95% confidence interval (CI).
Result: The study found that only 34% of households had one insecticide-treated net (ITN) for every two people—however, 76% of households owned at least one ITN. The ownership rate was higher for households with more sleeping rooms (adjusted OR=2.75; 95% CI 1.22-6.19). The utilisation rate of ITNs in the study setting was 53%. The most common reasons for not using ITNs were bed bugs, lack of hanging space, and insufficient mosquito nets. Married households had higher odds of using ITNs (aOR=1.65; 95% CI 1.14-2.39) than unmarried households. Moreover, households with smaller families (≤5 family members) had a higher rate of ITN utilisation than larger ones (>5 family members) (aOR=2.22; 95% CI 1.45-3.42).
Conclusion: In the study, ownership and use of ITNs were below the universal coverage goal of a one-bed net for two people. Additional bed net provision and awareness of their use are necessary to strengthen existing malaria prevention and control strategies.
Keywords: Malaria, Insecticide-treated bed nets, Ownership, Utilization
High prevalence of asymptomatic malaria in the lowlands of Gamo zone, south Ethiopia
Betelihem Jima, 1,2 Biniam Wondale1, Bernt Lindtjørn1, Fekadu Massebo1
1Department of Biology, Arba Minch University, Ethiopia 2Medical Laboratory Science, Hawassa University, Ethiopia
Introduction: Detecting parasites and gametocytes in asymptomatic cases in the community remains a challenge for malaria control efforts in malaria-endemic areas, as there are no easily accessible diagnostic tools available. Therefore, this study aims to determine the prevalence of malaria among asymptomatic individuals in the malaria-endemic district using a sensitive diagnostic technique.
Method: This is a baseline cross-sectional study for a randomised control trial aimed at controlling malaria using house screening and administration of cattle with ivermectin. The study was conducted between June 2023 and September 2023 in two selected districts endemic to malaria. Capillary blood was collected in the field to perform blood film and dried blood spot tests. The blood film was examined under a microscope to detect malaria, and the patients who tested positive were immediately provided with treatment. Parasite confirmation was done using a molecular technique.
Result: During a community screening, the prevalence of malaria by microscope was 3.4% (99 out of 2886). Among the positive cases, most (86%) were asymptomatic. Out of the 80 samples that tested positive by microscope, 64% (51) were re-confirmed as positive for malaria by molecular testing. Surprisingly, among the 142 samples that tested negative by microscope, 9% (13 out of 142) were found to be positive upon molecular testing. Among the positive cases, 47% (30 out of 64) were identified as Plasmodium falciparum, 50% (32 out of 64) were identified as Plasmodium vivax, and only 3% (2 out of 64) were mixed infections. Most malaria cases (73%) were found in participants under 15.
Conclusion: The study has shown that many malaria cases are asymptomatic, particularly among those under 15. This finding highlights the existence of malaria transmission within the community that is not easily detectable. Therefore, it is crucial to have accurate and sensitive diagnostic tools to identify asymptomatic malaria cases and provide timely treatment.
Keywords: Malaria prevalence, Asymptomatic cases, Molecular test, Ethiopia
Gametocyte density and carriage rate are higher in asymptomatic Plasmodium falciparum cases than in symptomatic cases in the lowlands of Gamo Zone, South Ethiopia.
Zerihun Zewde1,2, Teklu Wogayehu1, Demeke Daka3, Bernt Lindtjørn1, Fekadu Massebo1
1Department of Biology, Arba Minch University, Ethiopia 2Arba Minch Branch Public Health Laboratory, Arba Minch, Ethiopia 3Department of Biology, Madda Walabu University, Ethiopia
Background: To effectively control malaria, it is crucial to identify and treat every positive case within the community. Strategies like reactive case detection and prompt treatment can help reduce malaria transmission. However, paying attention to asymptomatic cases within the community is equally important, especially when assessing their gametocyte carriage rate.
Methods: A cross-sectional study investigated the reactive cases that emerged after the index cases. The index cases were examined at Sille Health Post by Rapid Diagnostic Kit (RDT). If RDT was unavailable, smeared slides were examined overnight at the Arba Minch Branch Public Health Institute Laboratory. Every person residing in the House of Index and Women’s Development Arm (consisting of 30-35 households), where the index cases originated from, was evaluated for malaria through RDT or microscopy within 3-6 days after the screening of the index case. Three laboratory technologists conducted microscopic readings: one for immediate parasite treatment, one blindly, and the third to resolve any conflicting results. The parasite and gametocyte density were determined by microscopy. The average of readings from all three technologists was used.
Results: During the study period, 184 index cases were identified. Subsequently, 2009 individuals were screened within the community. Out of the 2009 individuals screened, 82 tested positive, accounting for a prevalence rate of 4.1% of reactive cases. The reactive cases of P. falciparum showed a higher gametocyte density compared to the cases visiting a health facility. The mean gametocyte density of reactive cases of P. falciparum was 556.7 gametocyte/μl, while the corresponding density for the index cases was 54.4 gametocyte/μl.
On the other hand, the asexual parasite density of symptomatic cases visiting health facilities for both P. falciparum and P. vivax was significantly higher when compared to the reactive cases. Unlike P. falciparum, symptomatic cases of P. vivax patients visiting health facilities had a substantially higher gametocyte density than the asymptomatic cases found in the community. The mean gametocyte density of P. vivax index cases was 1427.4 gametocyte/μl compared to 313.0 gametocyte/μl in the reactive cases.
Conclusion: The study found that the number of gametocytes of P. falciparum was higher in the community among the asymptomatic than in symptomatic cases in health facilities. Early identification of infectious gametocyte reservoir cases using easily accessible diagnostic tools and prompt treatment within the community can help reduce transmission.
Keywords: Gametocyte density, Parasite density, Reactive cases, Index cases, Asymptomatic cases, Symptomatic cases
High prevalence of scabies and tungiasis in Gamo highlands, Southern Ethiopia
Alemayehu Bekele1,2, Wendemagegn Enbiale3, Daniel Woldiyes1, Fekadu Massebo1
1Department of Biology, Arba Minch University, Ethiopia 2 Collaborative Research and Training Center for Neglected Tropical Diseases, Arba Minch University, Ethiopia 3 Department of Dermatovenereology, Bahir Dar University, Ethiopia
Introduction: Scabies and tungiasis are two neglected diseases that can cause significant health problems, especially in communities with poor living conditions. Unfortunately, these diseases have not received enough attention in national and global health studies. Therefore, this study established the baseline prevalence of scabies and tungiasis in highland Kebeles. The results were intended to be used in a large randomised controlled trial to compare the effectiveness of administering single versus two oral doses of ivermectin in mass drug administration against these two diseases.
Methods: A physical skin examination was conducted on all residents in 32 selected clusters (30-35 households) in two Kebeles. Trained health officers examined 4,080 individuals between August and September 2023. The examination was carried out in daylight and in a private setting to ensure the privacy of the individuals. To minimise bias and ensure reproducibility, pictures of scabies and tungiasis cases were examined by two dermatologists.
Results: The study included 4,080 participants, with a mean age of 21 years and a standard deviation of 15 years. Females accounted for 52% (2,118) of the participants. Scabies were diagnosed in 506 individuals, which accounted for a prevalence of 12.4% (95% CI 11.4%, 13.4%). Of those 506 individuals, 44% (223) were aged between 5 and 14, while 39% (196) were over 15. A total of 516 study participants (12.6%) reported a history of scabies, but only 35 (6.8%) received treatment for it. The prevalence of tungiasis was 5.1% (209/4,080; 95% CI 4.4%, 5.8%). Most individuals with tungiasis were aged between 15 and 64 (72%, 150/209) and 35% (73/209) were aged between 5 and 14 years.
Conclusion: The high prevalence of scabies and tungiasis indicates the need for prompt and effective interventions. Mass drug administration using ivermectin, following the WHO guidelines, is recommended as a potential intervention strategy.
Keywords: Gamo Zone, Mass drug administration, Scabies, Tungiasis
Serological biomarkers of Plasmodium falciparum and P. vivax infections in the lowlands of Gamo Zone southwest Ethiopia
Mohammed Seid1,2, Teklu Wogayehu1, Fekadu Massebo1, Bernt Lindtjørn1
1Department of Biology, Arba Minch University, Arba Minch, Ethiopia 2Department of Medical Laboratory, Arba Minch University, Ethiopia
Introduction: In recent years, there has been a growing interest in using serological biomarkers for accurate estimations of malaria transmission and burden for epidemiological research and operational surveillance. However, only a few studies have assessed the recent and cumulative malaria infections in malaria-endemic areas in Ethiopia using validated serological biomarkers. This study aimed to evaluate the prevalence of Plasmodium falciparum and Plasmodium vivax infections among residents of malaria-endemic lowlands using multiple serological biomarkers.
Methods: A community-based cross-sectional study was conducted in malaria-endemic districts from July to September 2023. Antibody (IgG) response against multiple recombinant and protein antigens of P. falciparum and P. vivax was measured from eighty study participants’ serum elutes of a dried blood sample (DBS) using multiplex bead assay. Antibody responses to circumsporozoite protein (CSP), early transcribed membrane protein 5 (Etramp5.Ag1), glutamate-rich protein (GLURP-R2), apical membrane antigens (AMA1), and merozoite surface protein 1 (MSP-119) were analysed to determine the seroprevalence of P. falciparum. On the other hand, IgG responses against apical membrane antigen 1 (PvAMA1), reticulocyte binding protein (PvDBPR2), and merozoite surface proteins (MSP1–19) were analysed to determine recent and cumulative P. vivax infections.
Results: The overall seroprevalence of malaria infection was 27% (95% CI: 18 to 31%). The seroprevalence of recent P. falciparum infections was 15%, P. vivax infection was 13%, and mixed infections accounted for 1%. The cumulative prevalence biomarkers for P. falciparum infection were zero, but for P. vivax infection, it was 25%. Out of the individuals diagnosed with confirmed malaria cases through microscopic examination, only 14% showed the presence of biomarkers. The percentage of seropositivity rate for P. falciparum Etramp5.Ag1 was 15%, 25% for Pv AMA-1, and 13% for PvRBP2b.
Conclusion: The prevalence of malaria in the study area was 25%, based on indicators of cumulative and recent infection biomarkers. This highlights the need for continued control measures and serological surveillance testing.
Keywords: Biomarkers, Antibodies, Seroprevalence, Plasmodium species, Lumunex bead
High malaria prevalence in districts targeted to malaria elimination in southern Ethiopia: a community-based cross-sectional study
Teka Samuel, Tarekegn Solomon, Taye Gari, Misganu Endriyas, and Bernt Lindtjørn
Hawassa University, Hawassa, Sidama, Ethiopia
Background: Ethiopia’s ambition to eliminate malaria nationwide by 2030 is challenged by a recent rise in cases. Local information is required to enhance malaria prevention efforts at the regional and sub-regional levels. Therefore, this study aimed to determine the prevalence of malaria and its determinants in southern Ethiopia.
Methods: A community-based cross-sectional survey was conducted from February to March 2023 in two districts of the Sidama Region. Multi-stage cluster sampling was used to include 1647 households. A questionnaire was used to collect data on exposure variables, and a rapid diagnostic test was used to identify malaria infection. Malaria prevalence is calculated by dividing cases by those tested.
Results: Prevalence of malaria was 1.3% (n=94) among 6995 individuals tested. Most infections were caused by P. vivax47 (50%) or P. falciparum 43 (46%). Being female (AOR: 1.29; 95% CI: 1.01-1.63), being between the ages of 5 and 14 (AOR: 2.63; 95% CI: 1.45-4.77) compared to older than 15 years, having a family of fewer than five persons (AOR: 1.97; 95% CI: 1.18-3.29), and not using a bed net (AOR: 1.82; 95% CI: 1.24-2.66) were significantly associated with malaria.
Conclusion: Malaria was prevalent in the southern Ethiopian districts that were being targeted for elimination. A malaria control programme should promote the use of bed nets and take into account the demographic groups most at risk, especially women and children.
Key terms: Prevalence, Malaria, Sidama, Ethiopia
Larger families are less likely to achieve universal, long-lasting insecticidal net coverage and use in Ethiopia.
Misganu Endriyas, Tarekegn Solomon, Taye Gari, Teka Samuel and Bernt Lindtjørn
Hawassa University, Hawassa, Sidama, Ethiopia
Background: Sufficient access to and use of long-lasting insecticidal nets (LLIN) are crucial for malaria prevention. Hence, this study assessed the ownership and utilisation of LLINs in the Sidama Region, Southern Ethiopia.
Methods: A community-based cross-sectional study was conducted in February and March 2023. Multi-stage cluster sampling was used to select 1647 households with 8,054 individuals. We estimated LLIN coverage in terms of WHO’s universal LLIN coverage and National LLIN targets. LLIN utilisation was measured by the self-report of sleeping under LLINs the day preceding the survey and was estimated at household and individual levels.
Results: The ownership of at least one LLIN per household was 85%. About two-thirds (66%) of households had at least one LLIN for every sleeping space, and 49% had the required LLIN per family size. Only 36% of households had universal access to LLIN. Moreover, only 33% of households with under-five children or pregnant women had universal access to LLIN. Homes with larger families (Adjusted Odds Ratio (AOR): 8.14 [6.26, 10.58]) and female-headed households (AOR: 3.08 [1.47, 6.43]) were more likely to have unmet universal LLINs coverage. Of 1647 households, 85% owned at least one LLIN, and 78% (95% CI 76 – 80%) used at least one LLIN the preceding night. However, the individual-level LLIN use showed that only 31% slept under a bed net the previous day. Females (AOR: 1.5 (1.4, 1.7)) and members from large families (AOR: 1.3; 95% CI 1.1, 1.4) were more likely not to sleep under LLIN. Meanwhile, literate household members (AOR 1.2; 95% CI 1.1, 1.4) were likelier to sleep under bed nets than those who couldn’t read and write.
Conclusion: LLIN coverage was low compared to WHO-recommended universal LLIN coverage and national LLIN targets per sleeping space and family size. Therefore, the national LLINs distribution standard should consider additional LLINs for larger families. The proportion of the population in a malaria-endemic area who slept under LLIN the previous night was far below what is required to control malaria. Furthermore, measuring individual LLIN use may give more appropriate information for control than using the household as a unit, as often recommended.
Key terms: LLIN ownership, malaria, universal coverage
Effect of seasonal food accessibility on nutritional status of 15 – 49 years old women in Sidama, South Ethiopia
Bethelhem Mezgebe, Taye Gari, Mehretu Belayneh, Bernt Lindtjørn
College of Medicine and Health Sciences, Hawassa University, Hawassa, Ethiopia
Background: Food availability varies seasonally in most rural areas of developing nations, especially in areas affected by drought and climate change. This variability can impact food intake, household food security, and the nutritional status of residents, with women being one of the most vulnerable groups. Therefore, this study aimed to evaluate the association between household food accessibility and the nutritional status of women of reproductive age across four seasons in a year.
Methods: An open cohort study of women aged 15–49 was conducted in two woredas of Sidama National Regional State from June 2021 to June 2022, with follow-up visits every three months. A multistage sampling technique was employed to select 910 households. Anthropometric measurements were conducted along with interviews. The outcome variables included body mass index (BMI), household food insecurity, household dietary diversity, household weekly food consumption, and wealth index. Data were entered into EpiData version 3.1 and analysed using STATA version 15. Friedman test and Wilcoxon signed-rank test were utilised to compare non-normally distributed data across seasons. Linear regression was employed to identify determinant factors of women’s nutritional status, with a p-value of <0.05.
Results: On average, 1,050 women in the reproductive age group were followed up for 12 months. There was a significant difference in the median household food insecurity score between the pre-harvest and post-harvest periods (p-value < 0.001, w=0.18), as well as in the household dietary diversity score (p-value 0.008, w=0.007), household weekly food consumption score (p-value < 0.001, w=0.025), and wealth index (p-value 0.001, w=0.10). Among all observations, 17.0% (666/3,911 observations) of women were categorised as undernourished, 78.5% (3,070/3,911) had normal weight, and 4.5% (175/3,911) were overweight or obese. Women’s average BMI (95% CI) was 20.4 kg/m²(20.35, 20.5). The highest average BMI (95% CI) was observed in December (20.6, 20.5, and 20.8), while the lowest average BMI (95% CI) was observed in September (20.2, 20, 20.3). The average BMI of single women was higher than that of married women (0.52, 0.31, 0.74), and women with a primary school educational status had a higher average BMI than those who could read and write (0.26, 0.02, 0.51). Age β (95% CI) 0.03 (0.02, 0.04), household food insecurity score -0.03 (-0.04, -0.02), household dietary diversity score 0.12 (0.07, 0.16), previous season BMI 0.92 (0.9, 0.94), and previous season household food insecurity score 0.01 (0.004, 0.02) were identified as determinant factors of women’s BMI.
Conclusion
In this, better household food accessibility has been seen in postharvest season; following this, there was a slight improvement in average BMI. The probability of thin women in the previous season being thin in the coming season was high. Therefore, nutritional intervention should consider such seasonal variation, focusing on undernourished women.
Understanding Undernutrition among Pregnant Women in Rural Ethiopia: A Qualitative Study Using a Human-Centered Design Approach
Nana Chea 1*, Paul Groen 2, Mathe Mengesha4, Ayalew Astatkie 1, Mark Spigt 2, 3
1 School of Public Health, College of Medicine and Health Sciences, Hawassa University, Hawassa, Ethiopia 2 School CAPHRI, Care and Public Health Research Institute, Maastricht University, Maastricht, Netherlands 3 General Practice Research Unit, Department of Community Medicine, the Arctic University of Tromsø, Norway 4 Sidama Public Health Institute, Hawassa, Ethiopia
Background: In rural Ethiopia, undernutrition persists among pregnant women, harming both mothers and their unborn children. Despite efforts, the problem continues, requiring a comprehensive approach considering socio-cultural, economic, and situational factors. This study employed a qualitative human-centred design better to understand undernutrition among pregnant women in rural Ethiopia.
Methods: We conducted a phenomenological study in three districts of rural Ethiopia in 2022. Eighteen in-depth interviews and eight focus group discussions involving mothers and healthcare workers were conducted using the double-diamond model. Data were audio recorded, transcribed, and translated, and thematic inductive and deductive code analysis was supported by data analysis software ATLAS.ti, version 7.0.92.
Result: Food scarcity, gender inequality, a decline in nutritional education at maternal health services and initiatives, and a resulting lack of nutritional knowledge were identified as leading causes of undernutrition among pregnant women in rural Ethiopia. The participants emphasised that the most effective approach to address undernutrition among pregnant women involves closing the current gap in nutritional knowledge and practices among pregnant women, husbands, and mothers-in-law. They also proposed enhancing nutritional education provided during maternal healthcare services and initiatives like the pregnant women’s forum. Moreover, they highlighted the importance of reducing gender inequalities to impact this issue significantly.
Conclusion: Women and healthcare workers identified key factors contributing to the persistently high prevalence of undernutrition among pregnant women in rural Ethiopia. To address this issue, interventions should prioritise improving knowledge, optimal nutrition and addressing inequalities through cross-sector collaboration.
Keywords: Human-centered design, undernutrition, qualitative study, pregnant women, Ethiopia
Poor performance of laboratory professionals on malaria microscopy at Health Centers, Gamo Zone, Southern Ethiopia
Orzama Bala1,2, Teklu Wogayehu1, Fekadu Massebo1 and Biniam Wondale1
1Department of Biology, Arba Minch University, Ethiopia 2Regional Public Health Institute, Arba Minch, Ethiopia
Background: Microscopy has been a reliable diagnostic method for detecting malaria parasites, and it is currently used in all health centres across Ethiopia. However, the accuracy of the results primarily depends on laboratory professionals’ performance. Therefore, this study aimed to assess the proficiency level of laboratory professionals in malaria microscopy at health centres in malaria-endemic regions of the Gamo Zone, Southern Ethiopia.
Methods: Between April and June 2022, a cross-sectional study was conducted at health facilities. A structured questionnaire was used to collect socio-demographic data. Experts at the Regional Public Health Institute read malaria slides collected consecutively from health centres. PCR-confirmed positive and negative panel slides were distributed to laboratory professionals at health centres. The level of performance agreement was calculated using kappa statistics.
Results: Six health centres and 19 laboratory professionals participated in this study. Of the laboratory professionals, 84% (16/19) were diploma holders. The species identification performance of laboratory professionals in the routine malaria slide re-checking compared to experts at the Regional Public Health Institute showed perfect agreement for P. falciparum (90.8%; k = 0.81) and substantial agreement for P. vivax (88.3%; k = 0.76). Whereas, using the PCR-confirmed panel test, there was an agreement for P. falciparum (88.6%; k = 0.80) and fair agreement for both P. vivax (57.0%; k = 0.3) and mixed infection (71.1%; k = 0.24). None of the laboratory professionals could accurately report the parasite load of the panel slides despite three attempts to do so.
Conclusions: Laboratory professionals in the study area exhibited poor performance in detecting P. vivax and mixed infections and could not report parasite load. Therefore, it is recommended that laboratory professionals receive training in species identification and parasite load counting.
Keywords: Malaria diagnosis, Laboratory professionals, Microscopic performance,
Growth Velocity of Young Children in Sidama Region, Ethiopia: Preliminary Results
Dawit Jember Tesfaye, Taye Gari Bernt Lindtjørn
Hawassa University
Background: Malnutrition is a widespread public health problem in the world. Modelling growth velocity has become an attractive approach for the early identification of growth problems and provides evidence of the time and corrective actions required to improve childhood growth. However, evidence on the growth velocity of children is scarce in an area where food insecurity and undermatron are prevalent. This study aims to analyse children under five’s weight and height velocity curves in the Boricha and Bilate districts of the Sidama region, Ethiopia.
Methods: We analysed secondary data from an ongoing community-based cohort study. Children (5 to 55 months of age) and their mothers were followed four times yearly. Nine rounds of data collected from June 2021 to June 2023 were used in this preliminary analysis. The outcome variables were height and weight velocity. Children with less than three anthropometric measurements and height or weight size <-4 and >4 standard deviations were excluded from the analysis. Super Imposition Translation and Rotation (SITAR) and Generalized Additive Mixed Model (GAMM) models were used to perform growth curve analysis using R programming language.
Results: In total, 268 children (140 female and 128 male) were included, totalling 1719 observations. Over one-third (35%) were delivered at home, and only 50% started complementary food at six months. The mean (±SD) height at the first follow-up was 80.6 cm (3.26) and increased to 88.6 cm at the ninth follow-up, while the mean height and weight velocity decreased as age increased. The height velocity curves obtained from the SITAR and GAMM models were different. Age at Peak Height Velocity (APHV) and Peak Height Velocity (PHV) were (SITAR: APHV=1.7 years, PHV= 20.6 cm/year; and GAMM: APHV=0.42 year, PHV=10 cm/year). The SITAR model did not converge for weight velocity, while GAMM predicted age at peak weight velocity was 0.42 kg/year and peak weight velocity of 2.5 kg/year.
Conclusion: The height and weight velocity of the participants were lower in all age ranges than the expected velocity. The observed slow growth velocity might imply a high prevalence of undernutrition in the study area.
Where are the dropouts for a maternal continuum of care after the initiation of ANC in Sidama Regional State?
Yemisrach Shiferaw, Wondwosewn T/Silasie, Yaliso Yaya, and Achamyelesh G/Tsadik
Hawassa University
Introduction: Maintaining a continuum of maternal care by skilled providers during pregnancy, childbirth, and after delivery is a key strategy to save the lives of mothers and newborns. Besides, there is universal coverage for at least one ANC for rural women whose maternal continuum of care coverage is very low. Knowing the specific area of dropout in the path of the continuum of care is very important for further intervention. However, where the dropout occurs was unknown for rural women. This study aims to identify the dropout in the maternal continuum of care path and its associated factors for women living in the rural Sidama Regional State of Ethiopia.
Methods: A community-based cross-sectional study was conducted on 1830 reproductive-age women who gave birth in the last year at 40 selected kebeles of four districts in Sidama. A simple random selection of the sub-village was applied, and all eligible women were included until the fixed sample for the cluster was obtained. Dependent variables were Discontinuity of care of Maternal Continuum of care variables (Had at least one to three ANC visits and had no ANC4; had 4ANC visits but no ID; had 4ANC visits and ID but no PNC visit; had 4ANC visits and ID and one PNC visit). The independent variables were socio-demographic and health system-related variables. Descriptive statistics were employed to identify where the dropout and Multinomial logistic regression was done to determine the predictors of dropout at a different level in the path of the maternal continuum of care. Adjusted odds ratio (AOR) was reported with 95% confidence interval and p-value <0.05.
Result: Of the women, 1716 who had at least one ANC follow-up, 1393 (76.8%) were dropped before ANC 4, 37(2%) before institutional delivery, and 47(2.6%) before the postnatal period. Only 239 (13.2%) completed the maternal continuum of care. Educational status, [AOR= (CI) 0.85(0.79, 0.92)] Occupational status [AOR= (CI) (0.918 (0.881, 0.957)], community health insurance [AOR= (CI) 0.38 (0.28, 0.51)], and community resource groups [AOR= (CI) 0.25, (0.18, 0.34)] have lower odds of discontinuation before ANC4, while did not refer mothers during labour had high odds of discontinuation before ANC 4 [AOR (CI) = 2.8 (1.9, 4.2)] compared to completion of maternal continuum of care. For dropout before delivery education [AOR= (CI) (0.86 (0.76, 0.97)], referred during labour [AOR= (CI) 0.51 (0.31, 0.83)] and during postnatal care occupation [AOR (CI) = 0.73 (0.66, 0.80)], community health insurance [AOR (CI) = 0.29 (0.14, 0.59)], and community resource groups [AOR= (CI) 0.07, (0.02, 0.22)] compared to completed maternal continuum of care.
Conclusion and recommendation: Very low coverage of the maternal continuum of care was identified, and most dropouts occurred before ANC 4. Intervention regarding improving the contention of ANC4 by increasing the role of community resource groups in the community, improving community health insurance, and improving referral access during labour recommended improving the maternal continuum of care.
Keywords: continuum of care, maternal health care, Antenatal, Institutional delivery, postnatal