Health facility delivery is one of the critical indicators to monitor progress towards the provision of skilled delivery care and reduction in perinatal mortality. In Ethiopia, utilization of health facilities for skilled delivery care has been increasing but varies greatly by region and among specific socio-demography groups. We aimed to measure the prevalence and determinants of health facility delivery in the Amhara region in Ethiopia. From December 2018 to November 2020, we conducted a longitudinal study from a cohort of 2801 pregnant women and described the location of delivery and the association with determinants. We interviewed a subset of women who delivered in the community and analyzed responses using the three delays model to understand reasons for not using health facility services. A multivariable poisson regression model with robust error variance was used to estimate the presence and magnitude of association between location of delivery and the determinants. Of the 2,482 pregnant women followed through to birth, 73.6% (n = 1,826) gave birth in health facilities, 24.3% (n = 604) gave birth at home and 2.1% (n = 52) delivered on the way to a health facility. Determinants associated with increased likelihood of delivery at a health facility included formal maternal education, shorter travel times to health facilities, primiparity, higher wealth index and having attended at least one ANC visit. Most common reasons mothers gave for not delivering in a health facility were delays in individual/family decision to seek care. The proportion of deliveries occurring in health facilities is increasing but falls below targets. Interventions that focus on the identified social-demographic determinants and delays are warranted.

Importance Although there has been a reduction in stunting (low-height-for-age and low-length-for-age), a proxy of malnutrition, the prevalence of malnutrition in Ethiopia is still high. Child growth patterns and estimates of stunting are needed to increase awareness and resources to improve the potential for recovery. ObjectiveTo estimate the prevalence, incidence, and reversal of stunting among children aged 0 to 24 months. Design, Setting, and ParticipantsThis population-based cohort study of the Birhan Maternal and Child Health cohort in North Shewa Zone, Amhara, Ethiopia, was conducted between December 2018 and November 2020. Eligible participants included children aged 0 to 24 months who were enrolled during the study period and had their length measured at least once. Data analysis occurred from Month Year to Month Year. Main Outcomes and Measures The primary outcome of this study was stunting, defined as length-for-age z score (LAZ) at least 2 SDs below the mean. Z scores were also used to determine the prevalence, incidence, and reversal of stunting at each key time point. Growth velocity was determined in centimeters per month between key time points and compared with global World Health Organization (WHO) standards for the same time periods. Heterogeneity was addressed by excluding outliers in sensitivity analyses using modeled growth trajectories for each child. Results A total of 4354 children were enrolled, out of which 3674 (84.4%; 1786 [48.7%] female) had their length measured at least once and were included in this study. The median population-level length was consistently below WHO growth standards from birth to 2 years of age. The observed prevalence of stunting was highest by 2 years of age at 57.4% (95% CI, 54.8%-9 60.0%). Incidence of stunting increased over time and reached 51.0% (95% CI, 45.3%-56.6%) between ages 12 and 24 months. Reversal was 63.5% (95% CI, 54.8%-71.4%) by age 6 months and 45.2% (95% CI, 36.0%-54.8%) by age 2 years. Growth velocity point estimate differences were slowest compared with WHO standards during the neonatal period (-1.4 cm/month for girls and -1.6 cm/month for boys). There was substantial heterogeneity in anthropometric measurements. Conclusions and Relevance The evidence from this cohort study highlights a chronically malnourished population with much of the burden associated with growth faltering during the neonatal periods as well as after 6 months of age. To end all forms of malnutrition, growth faltering in populations such as that in young children in Amhara, Ethiopia, needs to be addressed.

ABSTRACT Objective Although there has been a reduction in stunting (low height/length for age), the prevalence of malnutrition in Ethiopia is still high. Child growth patterns and estimates of stunting are needed to determine vulnerabilities and potential for recovery. We collected longitudinal data to determine the prevalence, incidence and reversal of stunting among children aged 0-24 months. Methods We conducted a cohort study of 4,354 children between December 2018 and November 2020 in the Birhan maternal and child health cohort in North Shewa Zone, Amhara Ethiopia. Children who had their length measured at least once were included in this study. Results Among the 4,354 children enrolled, 3,674 (84.4%) were included. Our findings indicate that median population-level length is consistently below global standards from birth to age two. Growth velocity was slowest compared to global standards during the neonatal period and after children reached six months of age. The observed prevalence of stunting was highest at age two (57.9%). Incidence of stunting increased over time and reversal was highest between the ages of birth to six months. We found substantial heterogeneity in anthropometric measurements, which we addressed by fitting modeled growth trajectories for each child. Conclusion Overall, the evidence from this study highlights a chronically malnourished population with much of the burden driven by growth faltering during the neonatal periods as well as after 6 months of age. To end all forms of malnutrition, growth faltering in populations such as that in young children in Amhara, Ethiopia needs to be addressed. Article Summary Through longitudinal anthropometry data from birth to two years of age, we provide rigorous evidence on the burden, incidence and reversal pattern of childhood stunting. What is Known on This Subject There is a high prevalence of childhood stunting in Ethiopia. Prior studies show high spatial heterogeneity with highest prevalence in the Amhara region. Ethiopia aims to reduce stunting in children under 5 to meet global targets but remains off track. What This Study Adds We provide longitudinal data and modeled trajectories to describe patterns of linear growth and onset of growth faltering or recovery. The evidence generated serves as critical input to meet national and global targets of ending malnutrition. Contributors Statement Page Dr Frederick G. B. Goddard conceptualized and designed the study, curated the data, carried out the initial analyses and interpretation of data, drafted the manuscript and critically reviewed and revised the manuscript for important intellectual content. Dr Bezawit M. Hunegnaw conceptualized and designed the study, designed the data collection instruments, supervised data collection, contributed to analyses and interpretation of data, drafted the manuscript and critically reviewed and revised the manuscript for important intellectual content. Dr Sebastien Haneuse and Jonathan Luu contributed to analysis and interpretation of data, and critically reviewed and revised the manuscript for important intellectual content. Dr Mesfin Zeleke, Yahya Mohammed, Chalachew Bekele and Daniel Tadesse contributed to the design of data collection instruments, supervised data collection and critically reviewed and revised the manuscript for important intellectual content. Meles Solomon contributed to the interpretation of data and critically reviewed and revised the manuscript for important intellectual content. Dr Delayehu Bekele oversaw study implementation, contributed to the design of data collection instruments, critically reviewed and revised the manuscript for important intellectual content. Dr Grace J. Chan obtained funding, conceptualized and designed the study, contributed to analyses and interpretation of data, and critically reviewed and revised the manuscript for important intellectual content. All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

Introduction: Globally around 5 million children under the age of 5 years die every year. Ethiopia is one of five countries that contribute to more than half of these deaths. In the absence of a national vital registry system in Ethiopia, there is a lack of high-quality data regarding causes of death. Methods: We conducted a verbal autopsy study among under-five deceased children at the Birhan health and demographic site (HDSS) located in the North Shewa zone, Ethiopia. All deaths of under five children, which occurred in the time period from March 1, 2019 to February 29, 2020 at the Birhan HDSS, were identified. The under-five mortality rate (U5MR) was computed using a Kaplan-Meier approach. The world health organization verbal autopsy questionnaire was administered to mothers or caregivers of the deceased child after a minimum mourning period of 42 days. The causes of death were then determined by the InterVA-5 algorithm. Results: There were 90 under-five deaths resulting in an estimated U5MR of 45.3 per 1000 live births. The majority (62.2%) of deaths occurred during the neonatal period. The leading causes of death in under-five children were birth asphyxia (20, 27.0%), prematurity (19, 25.7%) and meningitis and encephalitis (8, 10.8%) while leading causes of neonatal deaths were birth asphyxia (19, 38.0%), prematurity (18, 36.0%) and neonatal sepsis (6, 12.0%). Conclusions: There is a high under-five mortality rate at the study site, with most deaths occurring in the neonatal period. Birth asphyxia and prematurity contributed to more than half of the under-five deaths suggesting that follow-up and management during pregnancy, labor and delivery should be strengthened to avert a significant proportion of under-five deaths.

Importance Data on birth outcomes and early mortality are scarce, especially in settings with limited resources. Total births, both stillbirths and live births, are often not counted, yet such data are critical to allocate resources and target interventions to improve survival. Objective To estimate the prevalence of stillbirths, neonatal deaths, and medically vulnerable phenotypes, such as preterm births, small-for-gestational-age (SGA), large-for-gestational-age (LGA), and low-birth-weight (LBW) births, in a setting where these key indicators remain largely unknown. Design, Setting, and Participants This prospective pregnancy cohort study of women and their newborns was conducted between December 12, 2018, and November 5, 2020. The study was conducted in North Shewa Zone, Amhara, Ethiopia. Data were analyzed from July 2021 to May 2022. Main Outcomes and Measures Pregnancy status, gestational age, birth weight, and vital status were measured to estimate the prevalence of stillbirths, live births, and medically vulnerable live births (ie, preterm, SGA, LGA, and LBW births). For mortality outcomes, the prevalence of neonatal (overall, early, and late) and perinatal mortality were estimated. Results Among the 2801 enrolled women, the median (IQR) age at conception was 26.5 (22.2-31.0) years, and the median (IQR) gestational age at enrollment was 24 (17-31) weeks. Of the 2628 women (93.8%) with outcome data, 101 pregnancies (3.8%) resulted in an early loss (<28 gestational weeks). Among the 2527 remaining pregnant women, there were 2518 births between 28 and less than 46 weeks' gestation; 2459 (97.7%; 95% CI, 97.0%-98.2%) were live births and 59 (2.3%; 95% CI, 1.8%-3.0%) were stillbirths. Many newborns (41.7%) were born preterm, SGA, LGA, or LBW. The estimated prevalence was 15.1% (95% CI, 13.7%-16.6%) for preterm births, 23.1% (95% CI, 21.3%-25.1%) for SGA births, 10.6% (95% CI, 9.3%-12.1%) for LGA births, and 9.4% (95% CI, 8.2%-10.8%) for LBW births. Among live births, the overall prevalence of neonatal mortality was 3.1% (95% CI, 2.5%-3.9%); mortality was higher among preterm births (7.2%; 95% CI, 4.9%-10.4%), LBW births (12.2%; 95% CI, 8.2%-17.7%), and SGA births (4.1%; 95% CI, 2.6%-6.5%). The prevalence of early neonatal mortality was almost twice as high as the prevalence of late neonatal mortality. The perinatal mortality prevalence was 4.3% (95% CI, 3.6%-5.2%), with a 1.2:1 ratio of stillbirths to first-week deaths. Conclusions and Relevance These findings have important implications for newborn health and survival. For policy makers and programmers, accurate data on key indicators of neonatal health provide information for resource allocation and to evaluate progress. For researchers, the findings underlie the importance for further research to develop and deliver interventions that improve health outcomes.

Introduction Health systems are often weakened by public health emergencies that make it harder to access health services. We aimed to assess maternal, newborn and child health (MNCH) service utilisation during the first 6 months of the COVID-19 pandemic compared with prior to the pandemic. Methods We conducted a mixed study design in eight health facilities that are part of the Birhan field site in Amhara, Ethiopia and compared the trend of service utilisation in the first 6 months of COVID-19 with the corresponding time and data points of the preceding year. Result New family planning visits (43.2 to 28.5/month, p=0.014) and sick under 5 child visits (225.0 to 139.8/month, p=0.007) declined over the first 6 months of the pandemic compared with the same period in the preceding year. Antenatal (208.9 to 181.7/month, p=0.433) and postnatal care (26.6 to 19.8/month, p=0.155) visits, facility delivery rates (90.7 to 84.2/month, p=0.776), and family planning visits (313.3 to 273.4/month, p=0.415) declined, although this did not reach statistical significance. Routine immunisation visits (37.0 to 36.8/month, p=0.982) for children were maintained. Interviews with healthcare providers and clients highlighted several barriers to service utilisation during COVID-19, including fear of disease transmission, economic hardship, and transport service disruptions and restrictions. Enablers of service utilisation included communities' decreased fear of COVID-19 and awareness-raising activities. Conclusion We observed a decline in essential MNCH services particularly in sick children and new family planning visits. To improve the resiliency of fragile health systems, resources are needed to continuously monitor service utilisation and clients' evolving concerns during public health emergencies.

Introduction Reliable estimates on maternal and child morbidity and mortality are essential for health programmes and policies. Data are needed in populations, which have the highest burden of disease but also have the least evidence and research, to design and evaluate health interventions to prevent illnesses and deaths that occur worldwide each year. Methods and analysis The Birhan Maternal and Child Health cohort is an open prospective pregnancy and birth cohort nested within the Birhan Health and Demographic Surveillance System. An estimated 2500 pregnant women are enrolled each year and followed through pregnancy, birth and the postpartum period. Newborns are followed through 2 years of life to assess growth and development. Baseline medical data, signs and symptoms, laboratory test results, anthropometrics and pregnancy and birth outcomes (stillbirth, preterm birth, low birth weight) are collected from both home and health facility visits. We will calculate the period prevalence and incidence of primary morbidity and mortality outcomes. Ethics and dissemination The cohort has received ethical approval. Findings will be disseminated at scientific conferences, peer-reviewed journals and to relevant stakeholders including the Ministry of Health.

Abstract Background Early postpartum facility discharge negatively impacts mothers’ proper and effective use postnatal care. Cognizant of these facts, home-based postnatal care practices have been promoted to complement facility-based care to reduce neonatal mortality. This systematic review evaluated the effectiveness and cost-effectiveness of home-based postnatal care on exclusive breastfeeding practice and neonatal mortality in low-and-middle-income countries. Methods Randomized trials and quasi-experimental studies were searched from electronic databases including PubMed, Popline, Cochrane Central Register of Controlled Trials and National Health Service Economic Evaluation databases. Random-effects meta-analysis model was used to pool the estimates of the outcomes accounting for the variability among studies. Results We identified 14 trials implementing intervention packages that included preventive and promotive newborn care services, home-based treatment for sick neonates, and community mobilization activities. The pooled analysis indicates that home-based postpartum care reduced neonatal mortally by 24% (risk ratio 0.76; 95% confidence interval 0.62–0.92; 9 trials; n = 93,083; heterogeneity p < .01) with no evidence of publication bias (Egger’s test: Coef. = − 1.263; p = .130). The subgroup analysis suggested that frequent home visits, home visits by community health workers, and community mobilization efforts with home visits, to had better neonatal survival. Likewise, the odds of mothers who exclusively breastfed from the home visit group were about three times higher than the mothers who were in the routine care group (odds ratio: 2.88; 95% confidence interval: 1.57–5.29; 6 trials; n = 20,624 mothers; heterogeneity p < .01), with low possibility of publication bias (Coef. = − 7.870; p = .164). According to the World Health Organization’s Choosing Interventions that are Cost-Effective project recommendations, home-based neonatal care strategy was found to be cost-effective. Conclusions Home visits and community mobilization activities to promote neonatal care practices by community health workers is associated with reduced neonatal mortality, increased practice of exclusive breastfeeding, and cost-effective in improving newborn health outcomes for low-and-middle-income countries. However, a well-designed evaluation study is required to formulate the optimal package and optimal timing of home visits to standardize home-based postnatal interventions.

Low birth weight is a global public health problem for mortality and morbidity in any age group. The objective of this study is to investigate the effect of maternal anthropometric measurements on birth weight. A cross-sectional study was conducted from Nov 25, 2012, to Feb 25, 2013, in maternity public hospitals in Addis Ababa city, Ethiopia. The effect is investigated using correlation, linear regression, independent sample T-test, one-way ANOVA, and finally multivariate linear regression analysis. A total of 605 women and their newborns took part in this study and prevalence of low birth weight is 8.3%. On adjusted multivariate linear regression analysis, maternal anthropometric measurements did not have an effect on birth weight. Since maternal mid-upper arm circumference ≤ 20 cm and body mass index ≤18.5kg/m2 are almost nil in this study, generalization is difficult to general population where undernourished women are common in the rural Ethiopia and similar study is recommended in those areas. Antenatal care visits, gestational age, and female sex of newborn had statistically significant effect in determining the risk of low birth weight. Women who were living with large family members had a heavier newborn than counterparts. This might be due to the fact that pregnant women have better care and social support in Ethiopian context, so advising pregnant women to live with family members should be considered to enhance social support during pregnancy in Ethiopia. Maternal anthropometric measurements have no significant effect in determining birth weight in the city and we recommend similar studies where undernourished women are common.