Category Archives: Maternal mortality

Stillbirths in Ethiopia

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A stillbirth occurs when a foetus dies in the uterus and when foetal death occurs after 20 weeks gestation or the foetus weighs more than 400 grams. We use the term to distinguish it from live birth or miscarriage. Most stillbirths occur in full term pregnancies.

The Lancet recently presented a series of articles on stillbirths. We can confirm from our studies from south Ethiopia that stillbirths represent a huge problem. About 5% of all hospital births are stillbirths. And, in our birth registry data, about 1.4 per cent of registered births are labelled as stillbirths. Such figures are uncertain, and some neonatal deaths might be misclassified as stillbirths.

Results from our studies in Ethiopia demand that we need to address this issue. What are the causes? Can we do anything to reduce stillbirths in settings such as rural south-west Ethiopia? We now plan to recruit a new PhD student to investigate how stillbirths can be reduced in southwest Ethiopia.

 

Surgeons and civic-professionalism

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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

Achieving MDGs?

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The United Nations recently discussed the achievements so far in achieving the Millennium Development Goals. The goals aim to:

  • Eradicate extreme poverty and hunger
  • Achieve universal primary education
  • Promote gender equality and empower women
  • Reduce child mortality
  • Improve maternal health
  • Combat HIV/Aids, malaria and other diseases
  • Ensure environmental sustainability
  • Develop a Global Partnership for Development

The Prime Minister of Norway, Jens Stoltenberg and the Gordon Brown, former PM of Great Britain, underline that governments of poorer nations have to put resources into education and health, and not into corruption.

As I have outlined previously, corruption is widespread at health institutions. Fighting corruption is necessary because corruption reduces the resources available for health. Corruption also lowers the quality, equity and effectiveness of health care services, and it decreases the volume and increases the cost of provided services. Corruption also discourages people to use and pay for health services.

It is encouraging that world leaders talk about broadening the tax base, and identify fighting corruption as a means of achieving the MDGs. The leading donors should encourage governments to put in place mechanisms at each institution to reduce corruption. This should include such basic functions and proper accounting systems and mechanisms for independent financial audits.

Is Ethiopia reaching the development millennium goals (MDG)?

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ResearchBlogging.org

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

Birth registration

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We regard birth registries as a important part of our work to reduce maternal and neonatal deaths.

We started to register all births in some parts of our catchment area in 2010. The health extension workers in the local communities registers all births and maternal and neonatal deaths in their catchment area. Usually one health extension worker covers about 250 families. Our experience so far is that it is possible to do this within the existing community infrastructure.

During the first three months of registration we registered three maternal deaths in two woredas. Although the numbers are too small to calculate maternal mortality rates, they show us something important:

1. The hospitals in the areas were unaware that the deaths had occurred.

2. One of the women who died had been advised by the health extension worker to deliver at the hospital, but she refused. We do not know why she refused to go to the hospital.

If our aim is to significantly reduce maternal deaths, there is a need to strengthen the collaboration between hospitals and their local communities. This is a societal responsibility of all health workers, whether they are health specialists or health extension workers.

During the past years, local health authorities have set up routines for compulsory notification of diseases such as measles or cholera. We are discussing if a similar alert system is needed for maternal deaths. It could be a mechanism for health extension workers to refer more delivery cases to the hospitals, and thus increase the institutional deliveries. And, it would make the health authorities aware of all maternal deaths occurring in their communities.

Maternal Mortality in Ethiopia

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In a special issue of the Ethiopian Journal of Health Development, eight papers discuss important topics such as maternal mortality trends, infrastructure and resources available for maternal health, and maternal health care use.

The articles show there have been improvements in antenatal care coverage and Tetanus Toxoid immunization. Unfortunately, delivery by skilled attendants and post-natal care coverage remain low. Ethiopia is making little progress in the indicator (skilled attendance at birth) that is considered to be the most important predictor of maternal mortality.

One of the papers discusses how to interpret trend data on maternal mortality ratio. Comparing the results of 2000 and 2005 Ethiopian Demographic Health Survey show there appears to be a decline in maternal mortality. However, as the overlaps in the 95% confidence intervals overlap, we cannot be certain about the decline.

Reducing maternal deaths in south-west Ethiopia

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Deaths from maternal causes still represent the leading cause of deaths among women of reproductive age in Ethiopia. We work on a public programme with the Ministry of Health in South-west Ethiopia to improve maternal health and reduce maternal and neonatal deaths (population 2.8 million).

As seen from the First Half-year report 2010 for our project, the number of institutions carrying out Comprehensive Obstetric care has since 2008 increased from two hospitals to 7 institutions (five hospitals and two health centres). The number of Caesarean Sections is doubled, and many lives of mothers and children have been saved.

We hope by 2011 to enable four more health centres doing these essential functions.

Malaria mortality declines in Ethiopia

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ResearchBlogging.org BBC World Service citing the Global Fund (Early Evidence of Sustainable Impact on Malaria) reported yesterday that malaria mortality declined by almost 50% in Ethiopia. The Global fund report states a 54% decline in malaria cases and 48% decline in malaria deaths.

Are such figures true? Working on malaria research projects in south Ethiopia I can confirm that fewer malaria patients are admitted to health centres and hospitals. Our preliminary data show that people use bed nets, community health workers diagnose and treat malaria cases, and malaria deaths do not occur as often as previously.

But, we have learned that malaria is a focal disease. In our research on malaria and climate we observe the last years have been dry in large parts of south Ethiopia. After the rains we first see increases in the mosquito densities followed by increases in malaria cases. There are more mosquitoes and cases after the heavy rains in early 2010, compared with 2009. Although we believe that malaria control efforts are effective, we need more time to get a full picture on the links between interventions, malaria sickness and death and naturally occurring variations.

Recent demographic data show decline in under-five mortality rates in Ethiopia from 204 to 123 per 1000 live births between 1990 and 2005. Ethiopia shows good progress was observed in controlling HIV/AIDS and malaria, but not for tuberculosis (Otten M et al, 2009; Accorsi S et al, 2009). Although a downward trend was observed in the maternal mortality ratio, it is too early to reach any firm conclusion about the possibility of achieving MDG5 because of sampling variability (Hogan M et al, 2010).

The good achievements in controlling malaria and increasing immunisation coverage show that scheduled routine interventions is well handled by the current health care system. However, interventions that rely on clinical services near to households with 24h availability, such as skilled care at birth, are weak. With the good achievements on malaria and immunization coverage, Ethiopia now needs to strengthen health institutions such as hospitals and health centres.

Otten, M., Aregawi, M., Were, W., Karema, C., Medin, A., Jima, D., Kebede, W., Gausi, K., Komatsu, R., Korenromp, E., Low-Beer, D., & Grabowsky, M. (2009). Initial evidence of reduction of malaria cases and deaths in Rwanda and Ethiopia due to rapid scale-up of malaria prevention and treatment Malaria Journal, 8 (1) DOI: 10.1186/1475-2875-8-14

Accorsi, S., Bilal, N., Farese, P., & Racalbuto, V. (2010). Countdown to 2015: comparing progress towards the achievement of the health Millennium Development Goals in Ethiopia and other sub-Saharan African countries Transactions of the Royal Society of Tropical Medicine and Hygiene, 104 (5), 336-342 DOI: 10.1016/j.trstmh.2009.12.009

Hogan, M., Foreman, K., Naghavi, M., Ahn, S., Wang, M., Makela, S., Lopez, A., Lozano, R., & Murray, C. (2010). Maternal mortality for 181 countries, 1980–2008: a systematic analysis of progress towards Millennium Development Goal 5 The Lancet DOI: 10.1016/S0140-6736(10)60518-1

2009 report on “Reducing Maternal Mortality Project”

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Deaths from maternal causes represent the leading cause of deaths among women of reproductive age in Ethiopia. Thus, in line with the Millennium Development Goal for maternal health (MDG-5), this health project aims to reduce maternal mortality among the target population by two-thirds by 2015.

Experience from other countries show that two conditions are needed to reduce maternal deaths: Staff should be able to carry out comprehensive emergency obstetric care, and these services should be available to and used by pregnant women.

Vision and aims of project

In this public programme, we work with the Southern Nations, Nationalities and Peoples’ Regional State (SNNPRS) Health Bureau of Ethiopia (RHB) to improve maternal health and reduce maternal and neonatal deaths among the target population. The target population for this project are pregnant women in the following administrative areas of south-west Ethiopia:             Gamu Gofa Zone, South Omo Zone, Basketo Special Woreda, Dirashe Special Woreda and Konso Special Woreda.

The Project works with two levels of health institutions responsible for delivery services. Health extension workers are responsible for the kebele antenatal work, and hospitals and health centres are responsible for delivery services in the woredas and zones.

Our work has four components:

  1. Train non-clinician physicians (health officers) and midwives to carry out comprehensive emergency obstetric care (see
  2. Equip institutions to carry out comprehensive obstetric services
  3. Make delivery services available through health extension workers to all local communities and thus to pregnant women among a population of 2.6 million people.
  4. Using a simple, cost-effective, and sustainable tool to monitor maternal and newborn deaths. These community-based birth and death registries use health extension workers to register all births and deaths that occur in rural communities

Work in 2009

During 2009, 10 health officers, 10 anaesthetic nurses and 10 scrub nurses received training in Arba Minch Hospital. They now work at their home institutions. It is encouraging to see the these teams of health staff at Kemba and Konso Health centres, and Chencha, Saula, Gidole and Arba Minch hospitals routinely do emergency obstetrics, including caesarean sections. In November another four health officers and anaesthesia nurses started their training. In addition, we have trained about 150 HEWs and 30 midwives and clinical nurses.

Our project represents the first try In Ethiopia to train non-clinician physicians on a larger scale, and we are encouraged to see that comprehensive obstetric care is done at health centres in Konso and Kemba. In 2009, the number of caesarean sections increased by almost fifty per cent among our target populations, and the number of institutions routinely doing emergency obstetric care increased from two to seven.

Monitoring of work

As in many other African countries, Ethiopia lacks information on how many mothers die before, during or after delivery. Thus, by involving staff from regional health authorities, universities and health colleges, we have developed tools for community based birth registries. In 2009 we carried out pilot studies, and validated the tools to register births and deaths. In December we started birth and death registration for the population in Dirashe Special Woreda. This registration will enable the project to oversee if maternal deaths are reduced by two-thirds by 2015. Two master students now study at Gondar University, and one PhD student shall soon start at the University of Bergen.

We use experienced staff to follow and support the health officers at the rural institutions. In addition we continuously review the quality of the work at all institutions. So far, the results are encouraging and are comparable similar work started in other African countries.

Priorities for 2010

In 2010 we shall continue to strengthen the institutions, and through our Quality assurance, we systematic monitor and evaluate the work to ensure that standards of quality are being met. In 2010, our main emphasis shall be to strengthen the capacity of health extension workers, health posts and smaller health centres. The goal is to improve institutional birth coverage and that pregnant women in need of institutional care are referred in time.

More information is found at:

http://www.lindtjorn.no/page1/page11/page11.html

http://bernt.w.uib.no/my-research-areas/reproductive-healthproject/reducing-maternal-and-neonatal-mortality/

http://bernt.w.uib.no/training-programme/