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  Our results (unpublished) show that maternal deaths have since 2008 been reduced by 2/3.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.

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

Research on reducing maternal and neonatal mortality in south-west Ethiopia

Ethiopia is among the countries in the world with most maternal deaths. As part of our project to reduce maternal deaths, we have started several studies to get the necessary information to follow and improve our intervention. 

Monitoring maternal and neonatal deaths
We aim to set up a simple, cost-effective, and sustainable tool to monitor maternal and newborn deaths in a remote part of south-west Ethiopia. We shall set up a community-based birth and death registry using health extension workers.

Data from this research will help us to monitor the intervention programme to reduce maternal and neonatal deaths. The registry is a model for Ethiopia, and may also help other countries to set up birth registries.

We shall use, and compare several designs such as population based registries, direct demographic models (surveys) and institutional registries to measure maternal and neonatal mortality.
The research is collaboration between Ministry of Health in Ethiopia, Arba Minch Hospital, Gidole Hospital, Arba Minch University and University of Bergen.

Developing training programmes for health officers
Through the programme to reduce maternal and neonatal mortality we train non-clinician physicians (health officers) to carry out comprehensive emergency obstetric care. We regularly evaluate the outcomes of the operations they do.

On a separate web page we have outlined

Later, we shall also write about our experiences in setting up emergency obstetric services, at health centres and small rural hospitals. This will also outline the equipment needed to carry out such work.

A model rural hospital

There are unfortunately many hospitals in Ethiopia and in Africa that do not work as expected. They lack staff, or equipment. Often they lack staff doing essential interventions such as caesarean sections.

Gidole Hospital is a district hospital in south-west Ethiopia. It was a busy mission hospital. When the expatriate staff left, the hospital more or less collapsed. There were fewer patients, and patients had to be transported to a referral hospital for emergency surgery.

Now the hospital works as a rural hospital again. Two dedicated health officers do essential obstetrics, including caesarean sections. They also do essential surgery such as management of fractures, and treatment of severe wounds. These improvements have also brought about other changes: more patients with other diseases use the hospital and patient revenues has increased.

In my definition, a rural hospital should:

  • have a good antenatal programme and be able to routinely do emergency obstetrics, including caesarean sections
  • be able to handle wounds and common fractures
  • be able to diagnose and treat common infections in paediatrics and internal medicine
  • should have tuberculosis and ART programmes
  • have a good relationship with the population in its catchment area

The hygienic standard at the hospital is acceptable. The floors are often washed, and the patients receive clean bedclothes. In addition, the hospital should be able to make enough income to sustain work and keep staff.

Gidole Hospital does not have a doctor now. It works adequately with non-clinician physicians. 

Curriculum for training NPC in Emergency Obstetrics and Surgery

As there is a severe shortage of trained health staff in rural Africa, we try to solve this issue by using doctors and non-physician clinicians (NPC).

Surgical care is the safe provision of preoperative, operative, and post-operative surgical and anaesthesia services. Unfortunately, there are too few surgeons in Africa, and it is unlikely that a modest increase in the number of surgeons and anaesthesiologists will occur. By enabling NPC to do some essential operations, we may increase benefits while lessening harm among populations where the unmet need of surgical care is great.

We train health officers (NPC) in Emergency Obstetrics and Surgery in south Ethiopia. It is a programme for public institutions, and it consists of four months basic training, followed by two months of supervisory visits to their home institutions. The curriculum can be downloaded here. An important part of the project is also to support the rural hospitals and health centres with essential equipment.

You can read more about our training programme and our experiences here.

Some lessons learned

To be able to reduce maternal mortality, two conditions should be met: Staff should be able to carry out comprehensive emergency obstetric care, and these services should be available to and used by the pregnant women.

About six months ago, we started to do caesarean sections at Saula Hospital in the inner part of Gamu Gofa. About 800.000 people live in these remote mountains.

Saula Hospital is a new hospital, which had not done any surgery before. We trained two operators (four months), two anaesthetist nurses (three months) and two scrub nurses. In addition we equipped the hospital with surgical instruments, an oxygen concentrator, suction machines and resuscitation equipment. Two experiences staff from Arba Minch Hospital taught the hospital staff how to handle and sterilize surgical equipments.

Our experience shows:

  1. It is possible to start emergency obstetric services, including operations such as caesareans sections and repair of uterine ruptures at places such as Saula. Non-specialists did the operations.
  2. The midwives correctly use partographs.
  3. Our review shows the indications to do surgery were correct. I believe the operations have saved many lives of mothers and neonates.
  4. Many women have severe complications already at admission to the hospital. This explains the high CS rate of about 20 %. It underlines that pregnant women in this remote part of Ethiopia come late for treatment.
  5. The number of uterine ruptures is high.
  6. Because of the late treatment, several of the women have developed vesico-vaginal fistulas.
  7. The complication rate for this newly started hospital is higher compared with operations done by non-clinician physicians at well-established hospitals. This underlines the importance in developing good and sound routines to ensure safe surgery.
  8. In our programme we review all operations, and we use a no-blame strategy to discuss complications.

One of the important lessons from Saula Hospital is to extend training the operators and anaesthetist nurses to five months at places where they shall start to do emergency operations. We also believe it is important to support and supervise such institutions for some years.

Now that Saula Hospital has set up the surgical and delivery services, emphasis must be to train midwives and nurses from the remote health centres to refer women to the hospital at an early.

Doctors and non-physician clinicians (NPC)

There is a severe shortage of trained health staff in rural Africa. We try to solve this issue by using doctors and non-physician clinicians (NPC). A recent problem we have seen in south Ethiopia is that these two categories of health personnel do not collaborate.

As non-physician clinicians (NPC) take over doing surgical tasks, the doctors withdraw from this important part of the work. General practitioners work on internal medicine and paediatrics, leaving surgery and obstetrics to NPC. In one hospital we have also seen the physician, who has only one year of clinical experience, leave the hospital when the non-physician clinician (NPC) started work.

This is a trend that worries us, and we need to find mechanisms to promote the collaboration between the two professions.

Any suggestions to solve this unhealthy competition?

Sustainability and task shifting in Africa

Recently Kathryn Chu and colleagues  wrote  a very good discussion on the topic of using non-physician clinician in emergency surgery (see Chu K, Rosseel P, Gielis P, Ford N (2009) Surgical Task Shifting in Sub-Saharan Africa. PLoS Med 6(5): e1000078. doi:10.1371/journal.pmed.1000078)

In a response to their paper, I wrote a comment on PLoSMedicine:

Kathryn Chu and colleagues are to be commended for their paper on “Surgical Task Shifting in Sub-Saharan Africa”.

I work on a project to train non-physician clinicians (NPC) in Emergency Obstetrics and surgery in south Ethiopia. The Ministry of Health collaborates and recognizes the training. It is a programme for public institutions, and it consists of four months basic training, followed by two months of supervisory visits to their home institutions. An important part of the project is also to support the peripheral institutions with essential equipment.

Our experience is similar to those from Mozambique and shows that using NPC for essential surgery and obstetrics is workable. Complication rates are low. As expected, we see that staff with some years of clinical experience perform better that those coming directly from school.

As many institutions have only one trained NPC, their sustainability is often threatened, and work might be discontinued during week-ends, vacations and needed travels. Each institution needs more than one team to become sustainable.

Too often, staff receive training and acquire basic skills to return to their home institution where it is not possible to do the tasks they trained for because of lack of follow up, surgical equipment or materials. For programmes to succeed, we think it is important to continue supporting the peripheral institutions.

As most peripheral hospitals and health centres are public, and to ensure sustainable performance, we believe the national or regional health authorities should own or be a part of the programme. This would allow for needed professional and political recognition, provision of necessary incentives and continued recruitment of essential staff.

Non-physician clinicians

We have good experience from sub-Saharan Africa, that task shifting from doctors to non-physician clinicians can address the HIV/AIDS treatment, improve tuberculosis control and manage health problems in children (IMC). Similarly, some operations usually done by surgeons and anaesthesiologists can be safely done non- specialists.

Surgical care is the safe provision of preoperative, operative, and post-operative surgical and anaesthesia services. Unfortunately, there are too few surgeons in Africa, and it is unlikely that a modest increase in the number of surgeons and anaesthesiologists will occur.

In HIV care, we recognized the Western model of care with medical specialists in secondary and tertiary hospitals, could not be copied in Africa. By adapting and selecting treatment protocols and task shifting, it was possible to treat millions of patients received antiretroviral drugs. Similarly, it is important in the surgical fields to avoid creating “islands of excellence in a sea of under provision”.

By enabling non-physician clinicians to do some essential operations, we may increase benefits while lessening harm among populations where the unmet need of surgical care is great.

Please also see a very good discussion on this topic written by Chu K, Rosseel P, Gielis P, Ford N (2009) Surgical Task Shifting in Sub-Saharan Africa. PLoS Med 6(5): e1000078. doi:10.1371/journal.pmed.1000078

For more information about our training programme in Ethiopia click here.