Report on Reducing maternal mortality projects in South Ethiopia (2013)

The aim of the work is to reduce maternal deaths, reduce deaths among newborns, and increase the number of deliveries at institutions. Our work aims to strengthen the health system by improving work at institutions doing comprehensive emergency obstetrics, and at health centres doing basic emergency obstetric care.

Our work, which consists of training, supervision and equipping and supporting institutions, focus to increase quality of services and better access for women to essential delivery services, and to improve health services for newborn. We thus work with health posts in kebeles, with health centres and hospitals.

We collaborate with the Midwife School in Arba Minch, and currently they are evaluating how good midwives do their work after they graduated from the school. This will give us essential information on how to improve the quality of midwife training, and thus of RMM type of 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. Our results show that maternal deaths have since 2008 been reduced by 2/3. The number of institutions doing comprehensive emergency care is now about one institution per 250.000 people, a dramatic improvement since 2007 when the figure was one institution per 2.5 million people. The institutional delivery rates have 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%. We believe the main reason for these good results is increased access to essential health care.

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.

Inadequate lifesaving emergency obstetric services in south-west Ethiopia

Girma M, Yaya Y, Gebrehanna E, Berhane Y, Lindtjorn B. 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.

Most maternal deaths take place during labour and within a few weeks after delivery. The availability and utilization of emergency obstetric care facilities is a key factor in reducing maternal mortality; however, there is limited evidence about how these institutions perform and how many people use emergency obstetric care facilities in rural Ethiopia. We aimed to assess the availability, quality, and utilization of emergency obstetric care services in the Gamo Gofa Zone of south-west Ethiopia.

We conducted a retrospective review of three hospitals and 63 health centres in Gamo Gofa. Using a retrospective review, we recorded obstetric services, documents, cards, and registration books of mothers treated and served in the Gamo Gofa Zone health facilities between July 2009 and June 2010.

There were three basic and two comprehensive emergency obstetric care qualifying facilities for the 1,740,885 people living in Gamo Gofa. The proportion of births attended by skilled attendants in the health facilities was 6.6% of expected births, though the variation was large. Districts with a higher proportion of midwives per capita, hospitals and health centres capable of doing emergency caesarean sections had higher institutional delivery rates. There were 521 caesarean sections (0.8% of 64,413 expected deliveries and 12.3% of 4,231 facility deliveries). We recorded 79 (1.9%) maternal deaths out of 4,231 deliveries and pregnancy-related admissions at institutions, most often because of post-partum haemorrhage (42%), obstructed labour (15%) and puerperal sepsis (15%). Remote districts far from the capital of the Zone had a lower proportion of institutional deliveries (<2% of expected births compared to an overall average of 6.6%). Moreover, some remotely located institutions had very high maternal deaths (>4% of deliveries, much higher than the average 1.9%).

Based on a population of 1.7 million people, there should be 14 basic and four comprehensive emergency obstetric care (EmOC) facilities in the Zone. Our study found that only three basic and two comprehensive EmOC service qualifying facilities serve this large population which is below the UN’s minimum recommendation. The utilization of the existing facilities for delivery was also low, which is clearly inadequate to reduce maternal deaths to the MDG target.

South Ethiopia Network of Universities in Public Health

The Norwegian Programme for Capacity Development in Higher Education and Research for Development (NORHED) recently told us that we have been awarded the project:  South Ethiopia Network of Universities in Public Health (SENUPH): improving women’s participation in post-graduate education. 

The vision of this project is to enhance the capacity of universities in south Ethiopia to train sufficient staff for the Region to carry out essential public health work, and do essential research to improve the health of the people living in South Ethiopia. This will be carried out by:

  • Establishing, and strengthening a network of the main universities in south Ethiopia doing teaching so the universities can increase their teaching capacity and train enough staff to meet the demands within the public health sector.
  • Substantially increasing the number of women with postgraduate education
  • Increasing the number of teachers at the universities in public health.
  • Strengthening the research capacity through PhD and Master’s programme so the research done in the region will aid in defining the future health policy.

This project has four integrated parts:

  • A PhD programme for all universities and located at Hawassa University
  • A master programme in Maternal and Reproductive health at Dilla University
  • A master programme in Nutrition at Wolaita Soddo University and
  • A master programme in medical entomology (malaria control) at Arba Minch University).

By developing a network of the main universities in south Ethiopia we will address several important areas such as staff development, and enhance the human capacity in higher education, in public health, reproductive health, and nutrition and malaria control.

The Southern Nations, Nationalities  and Peoples Region in Ethiopia has a population of about 16 million people, representing  more than 50 ethnic groups that live in a variety of geographic and socioeconomic areas. The area is typical of Ethiopia with high population densities, high fertility and child mortality rates, and high maternal death rates.

High maternal mortality in rural south-west Ethiopia

The Reducing Maternal Mortality project in south-west Ethiopia aims to reduce maternal and early child deaths. As part of this intervention project, we did several studies on estimating maternal mortality through a community-based birth registry, a retrospective 5-year recall period household survey, and a health facilities obstetric care quality study.

The abstract of the first publication is:

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

Background: Estimation of maternal mortality is difficult in developing countries without complete vital registration. The indirect sisterhood method represents an alternative in places where there is high fertility and mortality rates. The objective of the current study was to estimate maternal mortality indices using the sisterhood method in a rural district in southwest Ethiopia.

Method: We interviewed 8,870 adults, 15–49 years age, in 15 randomly selected rural villages of Bonke in Gamo Gofa. By constructing a retrospective cohort of women of reproductive age, we obtained sister units of risk exposure to maternal mortality, and calculated the lifetime risk of maternal mortality. Based on the total fertility for the rural Ethiopian population, the maternal mortality ratio was approximated.

Results: We analyzed 8503 of 8870 (96%) respondents (5262 [62%] men and 3241 ([38%] women). The 8503 respondents reported 22,473 sisters (average = 2.6 sisters for each respondent) who survived to reproductive age. Of the 2552 (11.4%) sisters who had died, 32% (819/2552) occurred during pregnancy and childbirth. This provided a lifetime risk of 10.2% from pregnancy and childbirth with a corresponding maternal mortality ratio of 1667 (95% confidence interval, 1564–1769) per 100,000 live births. The time period for this estimate was in 1998. Separate analysis for male and female respondents provided similar estimates.

Conclusion: The impoverished rural area of Gamo Gofa had very high maternal mortality in 1998. This highlights the need for strengthening emergency obstetric care for the Bonke population and similar rural populations in Ethiopia.

Avoiding maternal deaths

A recent report in The New York Times highlight the poor states and failures of hospitals in Uganda. They write about pregnant women arriving at hospitals in time to deliver, but when complications arise, no one is there to help them. The tragic events at Arua Hospital is unfortunately not a unique event.

Such failures are unfortunately not seldom. The New York Times article point to the lack of priority given by the Ugandan Ministry of Health. In my view it also points to a failure over many years by the international donor communities.

Where as much emphasis has been given to HIV work, and immunisations, donors and NGOs have been reluctant to support and strengthen institutions. Hospitals are essential to reduce maternal deaths. Most deaths would be averted if the pregnant women would deliver at hospitals near to their homes, and such a hospital need to have trained staff to do Comprehensive emergency obstetric care (see figure for more information).

Many NGOs and donor government unfortunately believe that providing antenatal coverage is enough to reduce maternal deaths. Unfortunately, such logic is only true to a certain extent. Good antenatal services will reduce maternal deaths if it works jointly with hospitals. Antenatal work in the communities and at peripheral health posts must in time refer women in need of comprehensive emergency obstetric care. Experience from many countries show that antenatal care as stand-alone work will not reduce maternal deaths.

In our project in Ethiopia we try to improve the quality of hospitals, and support the Ministry of Health to upgrade health centres to small hospitals so pregnant women can get use essential services near to their homes. The aim is there should be one well-functioning institution providing comprehensive emergency obstetric care for every 150.000 people.



Excellent for Centre for International Health

Recently, The Research Council of  Norway evaluated health research in Norway.

The core research groups at Centre for International Health both received the grade “Excellent” by an international expert panel which evaluated medicine and health research in Norway.

The evaluation panel concludes that “the Centre for International Health is the leading research centre within international and global health in the Nordic countries, and one of the leading centres in Europe”.

CIH combines biomedical and public-health research. Both the Child Health and Nutrition, and the HIV and TB Research group received “excellent” grades. Both research groups address important research questions, and base their research on long-term collaboration with universities in Asia and Africa. The research also addresses  the needs of the population, and translates research findings into improved treatment and better control of diseases.

Read the full evaluation report here.


Reaching MDG 5 by 2040?

Many African countries will not reach the Millennium Development Goals on health.

A recent article in The Lancet says only nine of 137 developing countries will achieve targets to improve the health of women and children. Although progress is speeding up in most countries, and especially to reduce child deaths, efforts to cut deaths among pregnant women and new mothers by three-quarters will not be achieved before 2040 in most sub-Saharan African Countries (see map copied from The Lancet article).

The reasons Africa fails on health MDGs are multifaceted, but most countries do not have the necessary health infrastructure where the people live. In simple language, this means that people do not have enough and good hospitals where they live. Thus, many pregnant women in need of help during deliveries do not get the help they need.

Unfortunately, many donors (rich countries and NGOs) focus on simple and cheap solutions, but not on the meticulous work in building small rural hospitals, and in training and supporting necessary staff.

Lozano, R., Wang, H., Foreman, K., Rajaratnam, J., Naghavi, M., Marcus, J., Dwyer-Lindgren, L., Lofgren, K., Phillips, D., Atkinson, C., Lopez, A., & Murray, C. (2011). Progress towards Millennium Development Goals 4 and 5 on maternal and child mortality: an updated systematic analysis The Lancet DOI: 10.1016/S0140-6736(11)61337-8

Can we trust community based birth registries?

Quality check household survey on community birth registry in Bonke woreda in Gamu Gofa Zone in South-west Ethiopia.

Recently Tadesse Data from Arba Minch finished his Masters’ of public health degree at Addis Continental Institute of Public Health and University of Gondar.

In many developing countries, we lack population based and accurate, reliable and complete population data, including birth registration. Recently, we started to register births, neonatal and maternal deaths using health extension workers in south-west Ethiopia.

In his research, Tadesse Data assessed the quality of birth registries done by health extension workers. Specifically, he assessed if the existing birth registries covered the whole population.

He did a community based cross-sectional household survey in Bonke Woreda in Gamo Gofa Zone in south-west Ethiopia. He randomly selected and surveyed 15 of the 30 kebeles (peasant associations) in the woreda (province). He asked about births that had occurred during the last 12 months, and examined if these births were registered in the birth registries.

The study identified 2724 births among a population of 78782. The crude birth rate was 34.5 per 1000 population, and similar to the expected 35 per 1000 population for Ethiopia. About 71 per cent of the births were registered in kebele birth registry. Most of the non-registered births lived in remote areas, and many did not attended antenatal follow up. Eighteen mothers died, and the maternal mortality rate in Bonke Woreda rate is 661 per 100.000 live births.

The study show that health extension workers can do community based birth registration. However, the health extension workers need regular supervision, and we need to improve the coverage of the antenatal services.


Low health care coverage in south-west Ethiopia

Assessment of availabiltiy and utlization af Emergency Obstetric Care Services In Gamo Gofa Zone, SNNRP, Ethiopia

Recently Meseret Girma Abate from Arba Minch University finished her Master of public health degree at Addis Continental Institute of Public Health and University of Gondar.

This work is a part of the research done for the programme to reduce maternal mortality in south-west Ethiopia. The following is an abstract of her research:

Most maternal deaths take place during labour and within few weeks after delivery. The availability and use of emergency obstetric care facilities is important to reduce maternal deaths. However, there is limited evidence how these institutions perform, and how many people use them in Gamo Gofa zone in south-west Ethiopia.

The objective of the thesis was to assess availability and use of emergency obstetric care services in Gamo Gofa zone in south-west Ethiopia.

For this study we did a cross-sectional survey of all 63 health centres and three hospitals  in Gamo Gofa. We did a retrospective review of obstetric services in Gamo Gofa zone in south-west Ethiopia. The data collectors visited each institution, observed the work, and interviewed the head nurses.

The main results show there were three basic and two comprehensive emergency obstetric care institutions per 1,740,885 population. Only 6.6% of all expected births were done by skilled attendants, and the caesarean section rate was 0.8%. Remote laying health institutions had lower number of births. The maternal mortality rate among births attending health institutions was 1900 per 100,000 live births.

The availability of basic and comprehensive emergency obstetric care facilities in south-west Ethiopia is far below the recommended health care coverage. The proportion of institutional deliveries and caesarean section rate is low.