Reducing stillbirths in Ethiopia

Lindtjorn B, Mitike D, Zidda Z, Yaya Y. Reducing stillbirths in Ethiopia: Results of an intervention programme. PLoS One. 2018;13(5):e0197708. Epub 2018/05/31. doi: 10.1371/journal.pone.0197708. PubMed PMID: 29847607.

Previous studies from South Ethiopia have shown that interventions that focus on intrapartum care substantially reduce maternal mortality and there is a need to operationalize health packages that could reduce stillbirths. The aim of this paper is to evaluate if a programme that aimed to improve maternal health, and mainly focusing on strengthening intrapartum care, also would reduce the number of stillbirths, and to estimate if there are other indicators that explains high stillbirth rates. Our study used a “continuum of care” approach and focussed on providing essential antenatal and obstetric services in communities through health extension workers, at antenatal and health facility services. In this follow up study, which includes the same 38.312 births registered by community health workers, shows that interventions focusing on improved intrapartum care can also reduce stillbirths (by 46%; from 14.5 to 7.8 per 1000 births). Other risk factors for stillbirths are mainly related to complications during delivery and illnesses during pregnancy. We show that focusing on Comprehensive Emergency Obstetric Care and antenatal services reduces stillbirths. However, the study also underlines that illnesses during pregnancy and complications during delivery still represent the main risk factors for stillbirths. This indicates that obstetric care need still to be strengthened, should include the continuum of care from home to the health facility, make care accessible to all, and reduce delays.


Smallpox and eliminating other diseases

 Dr. Donald A. Henderson, who led the World Health Organization’s war on smallpox, administering a smallpox vaccination in Ethiopia, around 1972. The last known case was in 1977. (Photo WHO)



Dr. Donald A. Henderson was an American physician who coordinated the World Health Organisation’s efforts to eradicate smallpox. After smallpox had been declared eradicated in 1980, he returned to the US, and became the Dean of what is now the Johns Hopkins Bloomberg School of Public Health. Dr. Donald A. Henderson died this month and will be remembered as a great scientist and public health physician.

As a child in late 1950s I remember a smallpox epidemic in Dilla in Ethiopia. I was so fortunate to have met this remarkable man, and listen to a talk he had at WHO in Geneva. Because of the success in eradicating smallpox, many believe that it also should be possible to eliminate other diseases such as poliomyelitis, Guinea worm, measles, or even malaria. I find it interesting to read that Dr Henderson was rather skeptical about these new eradication initiatives. Both the characteristics of the diseases, as well as the efforts put into getting rid of the diseases differed from what was the strategy to eradicate smallpox.

Tuberculosis in South Ethiopia

Mesay-Paper 1Dangisso MH, Datiko DG, Lindtjørn B (2014) Trends of Tuberculosis Case Notification and Treatment Outcomes in the Sidama Zone, Southern Ethiopia: Ten-Year Retrospective Trend Analysis in Urban-Rural Settings. PLoS ONE 9(12): e114225. doi:10.1371/journal.pone.0114225

Background: Ethiopia is one of the high tuberculosis (TB) burden countries. An analysis of trends and differentials in case notifications and treatment outcomes of TB may help improve our understanding of the performance of TB control services. Methods: A retrospective trend analysis of TB cases was conducted in the Sidama Zone in southern Ethiopia. We registered all TB cases diagnosed and treated during 2003–2012 from all health facilities in the Sidama Zone, and analysed trends of TB case notification rates and treatment outcomes.

Results: The smear positive (PTB+) case notification rate (CNR) increased from 55 (95% CI 52.5–58.4) to 111 (95% CI 107.4–114.4) per 105 people. The CNRs of PTB+ in people older than 45 years increased by fourfold, while the mortality of cases during treatment declined from 11% to 3% for smear negative (PTB-) (X2 , trend P,0.001) and from 5% to 2% for PTB+ (X2trend, P,0.001). The treatment success was higher in rural areas (AOR 1.11; CI 95%: 1.03–1.2), less for PTB- (AOR 0.86; CI 95%: 0.80–0.92) and higher for extra-pulmonary TB (AOR 1.10; CI 95%: 1.02– 1.19) compared to PTB+. A higher lost-to-follow up was observed in men (AOR 1.15; CI 95%: 1.06–1.24) and among PTB- cases (AOR 1.14; CI 95%: 1.03–1.25). More deaths occurred in PTB-cases (AOR 1.65; 95% CI: 1.44–1.90) and among cases older than 65 years (AOR 3.86; CI 95%: 2.94–5.10). Lastly, retreatment cases had a higher mortality than new cases (6% vs 3%).

Conclusion: Over the past decade TB CNRs and treatment outcomes improved, whereas the disparities of disease burden by gender and place of residence reduced and mortality declined. Strategies should be devised to address higher risk groups for poor treatment outcomes.

HIV among children in Ethiopia

Westerlund E, Jerene D, Mulissa Z, Hallström I and Lindtjørn B. Pre-ART retention in care and prevalence of tuberculosis among HIV-infected children at a district hospital in southern Ethiopia. BMC Pediatrics 2014, 14:250


Background  The Ethiopian epidemic is currently on the wane. However, the situation for infected children is in some ways lagging behind due to low treatment coverage and deficient prevention of mother-to-child transmission. Too few studies have examined HIV infected children presenting to care in low-income countries in general. Considering the presence of local variations in the nature of the epidemic a study in Ethiopia could be of special value for the continuing fight against HIV. The aim of this study is to describe the main characteristics of children with HIV presenting to care at a district hospital in a resource-limited area in southern Ethiopia. The aim was also to analyse factors affecting pre-ART loss to follow-up, time to ART-initiation and disease stage upon presentation.

Methods  This was a prospective cohort study. The data analysed were collected in 2009 for the period January 2003 through December 2008 at Arba Minch Hospital and additional data on the ART-need in the region were obtained from official reports.

Results   The pre-ART loss to follow-up rate was 29.7%. Older children (10-14 years) presented in a later stage of their disease than younger children (76.9% vs. 45.0% in 0-4 year olds, chi-square test, chi2 = 8.8, P = 0.01). Older girls presented later than boys (100.0% vs. 57.1%, Fisher’s exact test, P = 0.02). Children aged 0-4 years were more likely to be lost to follow-up (40.0 vs. 21.8%, chi-square test, chi2 = 5.4, P = 0.02) and had a longer time to initiate ART (Cox regression analysis, HR: 0.50, 95% CI: 0.25-0.97, P = 0.04, controlling for sex, place of residence, enrolment phase and WHO clinical stage upon presentation). Neither sex was overrepresented in the sample. Tuberculosis prevalence upon presentation and previous history of tubercolosis were 14.5% and 8% respectively.

Conclusions  The loss to follow-up is alarmingly high and children present too late. Further research is needed to explore specific causes and possible solutions.

Update: RMM projects in south-west Ethiopia

The aim of the RMM (Reducing Maternal Mortality) programme in Saggen, Gamo Gofa Zone and in Basketto is to reduce maternal and neonatal deaths.

RMM-institutionsDuring the first phase (2008 – 2011), we worked to set up and strengthen institutions doing Comprehensive Emergency Obstetric care (CEmOC). Arba Minch Hospital was the training centre, Saula Hospital and Chencha Hospital, and Kemba, Basketto and Melo Health Centres started to do caesarean sections through support by our project. All these institutions are now regularly doing caesarean.

The challenge we noted during the first phase was that large populations living in our target areas still have limited access to delivery services.

During the second phase (2012 – 2016) we aim to increase the coverage of Basic and Comprehensive Emergency Obstetric Care. Our aim is to improve the access to delivery services. We do this by strengthening health centres to do Basic Emergency Obstetric Care. We also link the work at these health centres to health posts in the kebeles, and to improve referrals to institutions doing caesarean sections.

During the last year the number of institutions doing Comprehensive Emergency Obstetric care (CEmOC) has increased by four; in Bonke woreda (Gezzeso), in Beto and in Selam Berr (Kucha), and in Kolme and in Gawada.. The map shows the institutions doing CEmOC on the area. So, The number of institutions doing comprehensive emergency care is now about one institution per 250.000 people, a great improvement since 2007 when the figure was one institution per 2.5 million people.

We also collaborate with the Midwife School in Arba Minch, and currently they are evaluating how well the midwives that graduated from their school are performing (See Master thesis by Rahel Tesfaye). This will give us essential information on how to improve the quality of midwife training, and thus of RMM work.

To monitor this work and see if the project meets its societal objectives (reduced death rates), we register births and maternal deaths in four woredas with a population of about 600.000. In a recent research we have shown that it is possible to achieve high coverage community birth registration in rural Ethiopia. Such registration can be an important tool to monitor births and birth outcomes such as maternal mortality in resource-limited settings (Yaliso et al 2014, PLoSONE in press).  Our results (unpublished) show that maternal deaths have since 2008 been reduced by 2/3. The institutional delivery rates have also increased substantially, and the use of traditional birth attendants is decreasing. We also see some early signs of decreasing neonatal deaths. In some areas the institutional delivery rates approach 60%.

Even if our results are encouraging, many challenges remain. The birth registration shows that highest maternal deaths rates are among women who live in remote areas, and among women who report illness during pregnancy. One study show that children born to poor women have higher death rates compared with richer families. So, in the coming years will focus on improved quality of care, particularly focusing on improving access, and on managing illness during pregnancy. We will also try to develop tools to identify the poor that are in need of special attention.


Yaya Y, Data T, and Lindtjørn B. Maternal mortality in rural south Ethiopia: Feasibility of community-based birth registration by Health Extension Workers.  (Manuscript submitted 2014).

Yaya Y, Eide KT, Norheim OF, Lindtjørn B (2014) Maternal and Neonatal Mortality in South-West Ethiopia: Estimates and Socio-Economic Inequality.PLoS ONE 9(4): e96294. doi:10.1371/journal.pone.0096294

Girma M, Yaya Y, Gebrehanna E, Berhane Y, Lindtjørn B. (2013). Lifesaving emergency obstetric services are inadequate in south-west Ethiopia: a formidable challenge to reducing maternal mortality in Ethiopia. BMC Health Services Research 2013; 13(1):459.

Yaya Y, Lindtjørn B (2012). High maternal mortality in rural south-west Ethiopia: estimate by using the sisterhood method. BMC Pregnancy and Childbirth 2012; 12: 136.

Rahel Tesfaye. Client Satisfaction with Delivery Care Services and Associated Factors in the Public Health Facility of Gamo Gofa Zone, South West Ethiopia. 2014. Arba Minch University and Addis Continental Institute of Public Health.

For complete list of publications from this project click here.

Maternal and Neonatal Mortality in South-West Ethiopia

Yaya Y, Eide KT, Norheim OF, Lindtjørn B (2014) Maternal and Neonatal Mortality in South-West Ethiopia: Estimates and Socio-Economic Inequality. PLoS ONE 9(4): e96294. doi:10.1371/journal.pone.0096294

Introduction  Ethiopia has achieved the fourth Millennium Development Goal by reducing under 5 mortality. Nevertheless, there are challenges in reducing maternal and neonatal mortality. The aim of this study was to estimate maternal and neonatal mortality and the socio-economic inequalities of these mortalities in rural south-west Ethiopia.

Methods  We visited and enumerated all households but collected data from those that reported pregnancy and birth outcomes in the last five years in 15 of the 30 rural kebeles in Bonke woreda, Gamo Gofa, south-west Ethiopia. The primary outcomes were maternal and neonatal mortality and a secondary outcome was the rate of institutional delivery.

Results  We found 11,762 births in 6572 households; 11,536 live and 226 stillbirths. There were 49 maternal deaths; yielding a maternal mortality ratio of 425 per 100,000 live births (95% CI:318–556). The poorest households had greater MMR compared to richest (550 vs 239 per 100,000 live births). However, the socio-economic factors examined did not have statistically significant association with maternal mortality. There were 308 neonatal deaths; resulting in a neonatal mortality ratio of 27 per 1000 live births (95% CI: 24–30). Neonatal mortality was greater in households in the poorest quartile compared to the richest; adjusted OR (AOR): 2.62 (95% CI: 1.65–4.15), headed by illiterates compared to better educated; AOR: 3.54 (95% CI: 1.11–11.30), far from road (≥6 km) compared to within 5 km; AOR: 2.40 (95% CI: 1.56–3.69), that had three or more births in five years compared to two or less; AOR: 3.22 (95% CI: 2.45–4.22). Households with maternal mortality had an increased risk of stillbirths; OR: 11.6 (95% CI: 6.00–22.7), and neonatal deaths; OR: 7.2 (95% CI: 3.6–14.3). Institutional delivery was only 3.7%.

Conclusion  High mortality with socio-economic inequality and low institutional delivery highlight the importance of strengthening obstetric interventions in rural south-west Ethiopia.

Improving tuberculosis control in Ethiopia

Ethiopia, with over 80 million people, is heavily affected by tuberculosis, complicated by poverty and HIV infection, limited access to the health service and shortage of health workers.

We recently reviewed tuberculosis control programme in South Ethiopia. Although treatment success rates have improved during the last decade, low case notification rate, mainly because of inability to access the health service, remains a challenge.

Using community health workers, we enrolled health extension workers (HEWs) in providing health education, sputum collection and providing treatment. This improved case detection, and more significantly for women, because the community-based sputum collection increased access to the diagnostic services. Similarly, community-based treatment improved the treatment success of smear-positive patients (90%) compared with to health facility-based treatment (83%). This approach also reduced the total costs by 63%. Thus, such interventions are economically attractive to the health service and patients, caregivers and the community.

Community based intervention improve access for the poor and for women to have better access to the health service. It is effective and an economically attractive alternative to the traditional health services.

By improving health service delivery to the affected community living in high burden countries, this is an example of how operational research in developing countries provide evidence for  policy change. Recently, this approach was endorsed by the Ministry of Health Ethiopia. Health Extension Workers shall now be involved in tuberculosis control in Ethiopia.

This research has been carried out by Daniel Gemechu Datiko. This week he defends his PhD at the University of Bergen. You can read his thesis at: Improving Tuberculosis Control in Ethiopia: Performance of TB control programme, community DOTS and its cost-effectiveness.

The two most important papers in his thesis are:

Datiko, D., & Lindtjørn, B. (2009). Health Extension Workers Improve Tuberculosis Case Detection and Treatment Success in Southern Ethiopia: A Community Randomized Trial PLoS ONE, 4 (5) DOI: 10.1371/journal.pone.0005443

Datiko, D., & Lindtjørn, B. (2010). Cost and Cost-Effectiveness of Treating Smear-Positive Tuberculosis by Health Extension Workers in Ethiopia: An Ancillary Cost-Effectiveness Analysis of Community Randomized Trial PLoS ONE, 5 (2) DOI: 10.1371/journal.pone.0009158

Surgeons and civic-professionalism

ResearchBlogging.orgSurgery is often the only solution to prevent disabilities and death from conditions resulting from pregnancy related complications, surgical conditions (example acute abdomen), infections, traffic accidents, falls, burns, disasters, domestic violence, and congenital defects.

Until recently, surgery was neglected as a developing country public health issue. Health officials, especially in the World Health organization and in major international Non-Governmental Organizations often viewed it as expensive and unnecessary tertiary care needing advanced equipment and expertise.

Recently, surgery is beginning to be seen as an integral part of primary health care. Often it is a preventive and a cost-effective way of dealing with many health challenges in poor countries. WHO now recommends that basic surgical services should be available in district hospitals, while more specialised surgery is performed at tertiary level hospitals.

A recent article in The Lancet (Funk, Weiser et al. 2010) show there are less than 1 surgical theatre per 100.000 people in Africa (14 times less than in Europe). In addition, there are too few surgeons, and 95% of these surgeons work in urban areas.

Addressing the inequities in access to essential surgery, an Editorial in the Lancet also underlined the need for improved professionalism and leadership among surgeons. The civic-professionalism should be addressed among surgeons in speaking for equity at local, national and global levels. (Editor 2010)

Death and disability in the most vulnerable groups (namely, women and children) are easily prevented or corrected by surgery. Most essential and surgical interventions can be delivered at the first referral level health institution (rural or district hospital, health centre, primary healthcare institutions) provided the health care staff know few basic skills and their institution have some basic equipment.

Priorities include work to:

• strengthen capacity to deliver effective emergency surgical care at the first referral level facility, and thus working towards achieving the WHO Millennium Development Goal 5 (reducing maternal deaths).

• improve the quality of care through safe and proper use of emergency and essential surgical procedures

• strengthen existing training and education programmes in safety of essential procedures

There are very few surgeons in South Ethiopia. We therefore train Non-Clinical Physicians to do essential obstetrics and surgery. Currently, this programme includes twelve institutions covering about 3 million people.

Editor (2010). “What is the point of surgery?” Lancet 376(9746): 1025.

Funk, L., Weiser, T., Berry, W., Lipsitz, S., Merry, A., Enright, A., Wilson, I., Dziekan, G., & Gawande, A. (2010). Global operating theatre distribution and pulse oximetry supply: an estimation from reported data The Lancet, 376 (9746), 1055-1061 DOI: 10.1016/S0140-6736(10)60392-3

Missing AIDS Patients

ResearchBlogging.orgIt is important for HIV infected patients to take their drugs regularly. Interruptions in treatment lead to viral strains that are resistant to the cheapest medications, and to higher rates of illness and death. Unfortunately, many AIDS patients do not come for their antiretroviral medications. Such patients are labelled as “lost to follow-up.”

During the early years of antiretroviral treatment (ART) drug distribution in Africa, researchers reported high rates of adherence to treatment, often as high as in Europe or the United States. At the same time, studies showed higher early mortality rates among patients treated with antiretroviral drugs in settings with limited resources. A reason for the high death rates was late presentation of patients to care.

In a recent review of 2191 adult HIV patients in south Ethiopia, we show that patients now start to present at earlier stages of their illness, and death has decreased among adult HIV patients. Early treatment start contributed to improved survival (Mulissa, Jerene and Lindtjørn, 2010).

Unfortunately, 25 per cent were lost before that started treatment. This means they were diagnosed, but did not return for treatment, and this have increased during the recent years. We also found that 15% per cent of those who start treatment were lost to follow up. 40% of the latter group had died, and 20% had started treatment in another institution.

Some ART programmes in Africa are experimenting with different programmes to reduce loss to follow-up. Some organizations offer a two- or three-month supply of medication for each clinic visit, others deliver drugs to patients’ homes, and some have tried to refund patients for transport costs. None of these efforts have been evaluated.

Mulissa, Z., Jerene, D., & Lindtjørn, B. (2010). Patients Present Earlier and Survival Has Improved, but Pre-ART Attrition Is High in a Six-Year HIV Cohort Data from Ethiopia PLoS ONE, 5 (10) DOI: 10.1371/journal.pone.0013268

Is Ethiopia reaching the development millennium goals (MDG)?

Although Ethiopia has shown an impressive economic growth over the last seven years, one-third of its population remains poor. To achieve the MDG, an annual economic growth of 7 % is needed, and in the last years the growth has exceeded this critical figure.

A recent conference in Cape Town evaluated the performance of different countries, including Ethiopia, on achieving the MGD goals 1. The country is making some progress on indicators such as vaccination coverage and malaria control. Child mortality rates are declining, and HIV care is improving. Unfortunately, only 11% of the population have good access to emergency obstetric care, and the levels of stunting, an indicator of chronic malnutrition and poverty, is not declining. Tuberculosis case detection rates remain low.

One way to compare access to health services is to use the coverage index. The index uses some indicators for eight reproductive, maternal, newborn and child interventions. They include family planning, maternal and newborn health (at least one antenatal visit and skilled attendant at delivery), immunisations (measles, BCG and DPT3) and curative childcare (diarrhoea and pneumonia management: oral rehydration and continued feeding and care seeking for pneumonia). Unfortunately, there is still a 80% health coverage gap for most Ethiopians, and for the more wealthy part of the population, the coverage gap is still 60%, one of the worst in Africa.

Currently a new health sector plan is being approved. Although the details of this plan remains unknown to the public, the vision of the government is to transform Ethiopia to become a middle-income country in a few years after the end MDG 2015. The most concrete step that I have heard about is to improve access to essential health services by setting up primary hospitals to serve a population of 60 – 100.000 people . Each primary hospitals shall provide emergency surgical services focusing on Comprehensive Emergency Obstetric Care. Improved access and improved infrastructure would in theory enable the government to reduce maternal deaths.

Full report:

1. WHO, UNICEF. Countdown to 2015 decade report (2000–2010): taking stock of maternal, newborn and child survival. Geneva: WHO and UNICEF; 2010.

Bhutta ZA, Chopra M, Axelson H, Berman P, Boerma T, Bryce J, Bustreo F, Cavagnero E, Cometto G, Daelmans B, de Francisco A, Fogstad H, Gupta N, Laski L, Lawn J, Maliqi B, Mason E, Pitt C, Requejo J, Starrs A, Victora CG, & Wardlaw T (2010). Countdown to 2015 decade report (2000-10): taking stock of maternal, newborn, and child survival. Lancet, 375 (9730), 2032-44 PMID: 20569843