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About half of maternal deaths in the world in 2005 occurred in Ethiopia, Nigeria, Democratic Republic of Congo, India and Afghanistan [1]. In Ethiopia, the maternal mortality ratio (MMR) was 720 per 100,000 live births in 2005, and about 90 times higher than in resource-rich countries. Reducing the maternal and neonatal mortality are the targets of the Millennium Development Goals 4 and 5 [2].

As it is true for most of Africa, Ethiopia lacks information for setting priorities and monitoring health interventions. Unfortunately, it is difficult to get reliable measures to follow the progress on interventions to reduce maternal and neonatal deaths.  Some of the tools used to estimate maternal and neonatal mortality rates provide temporary estimates, but are not so helpful in overseeing progress of interventions [3, 4]. There are few studies in Ethiopia that compares measures as the sisterhood method with population-based birth and death registration. In addition, our study represents an opportunity to link information between communities and health institutions.

This research is linked to an intervention programme (Reducing Maternal Mortality; see http://www.lindtjorn.no/page1/page11/page11.html) in south-west Ethiopia. Our aim is that this research will provide us with the tools to measure the impact of interventions.

Objectives

We aim to set up a simple and sustainable birth registry to oversee maternal and newborn deaths in a remote part of Ethiopia.

The overall aim of the study is to develop tools to monitor maternal and neonatal deaths in communities and health institutions in south Ethiopia, and to estimate effective coverage of emergency obstetric care.

Through this research we will estimate of the size of the problem, identify causes of maternal and neonatal deaths, and enable regular monitoring of progress.

Research objectives

These research objectives are:

1. To estimate maternal mortality ratio and identify risk factors for death
2. To determine neonatal mortality rate and identify risk factors for death
3. To estimate pregnancy-related deaths in the area using the direct sisterhood method
4. To assess the availability and performances of emergency obstetric care at institutions by reviewing the birth registries at hospitals and health centres.
5. To monitor trends in maternal and neonatal mortality rates by using community and institutional birth registries
6. To compare the results of maternal and neonatal death estimates by using population based registries, institutional registries and direct demographic methods.
7. To estimate effective coverage of emergency obstetric care

Expected outcomes of the research

Through this research we will get an estimate of the size of the problem, identify causes, and determinants, identify differences in levels within our catchment area and the research would enable regular monitoring of progress. It is a model for Ethiopia, and may also help other countries to set up similar registries.

Methods:

We shall use and compare several designs to measure maternal and neonatal mortality:

1. Population based registry: The Health Extension programme in focuses on preventive and promotive health care. Two women with one year training work as health extension workers in their kebeles (average population 5000 people). They receive a salary from the government, and work on disease prevention and health promotion conducted by house-to-house visits. As the HEWs regularly visit homes, they will learn about all births in their catchment area. We shall train HEWs to register births and deaths, and find out the possible causes of death using verbal autopsies. The population-based birth and death registry (se uploaded copy of registry form) is a prospective cohort to follow the outcomes of about 23,000 live births in four districts (Dirashe, Bonke, Arba Minch Zuria and Demba Gofa with a population of 592.000 people). The outcome measures are maternal deaths within 42 days, and death of newborn babies within 28 days after delivery. Here you can download The RMM-Birth-registry-form and the its English translation
2. Using the sisterhood and household death survey method [4] we shall collect data from Bonke district (population 173,000) to estimate maternal deaths in the  last 5 years.
3. Institutional based birth registry: In this retrospective review of 68 health institutions in Gamo Gofa Zone (population 1,6 million people), we  assess the standard and quality of obstetric care [5, 6], and record outcomes such as maternal and neonatal deaths, and birth complications.
4. The effective coverage framework points out what fraction of the potential health gain achievable through the interventions is being delivered. To estimate the effective coverage of emergency obstetric care, we shall use the method proposed by Shengelia and others [7]

Ethical issues:

This research does not contain any new intervention or drugs. Women in need of health care will be referred to the nearest institution. The study will be conducted according to the Declaration of Helsinki, and we shall get ethical clearance from the Ethical Review Board of the Southern Regional Health Bureau in Ethiopia. All study records will be maintained in a secured location.

Publication plan

We shall engage key stakeholders through meetings and workshops to ensure the research is relevant to the context. Communications approaches include: community groups; workshops; and meetings with key individuals. We shall tailor all communication to meet the needs of the groups and that messages are clearly communicated.

For each sub-objective, we shall publish papers in international peer-reviewed and open – access journals, and we shall present reports to central and regional health authorities in Ethiopia. We shall use the results from the research in teaching and training activities at UIB and Ethiopian universities.

Research collaboration

The research is collaboration between Ministry of Health in Ethiopia, Arba Minch University, Arba Minch Hospital, Gidole Hospital and University of Bergen.

Yaliso Yaya (BSc, MPhil), Arba Minch University and Arba Minch College of Health Sciences, PhD student (Quota scholarship).

Tadesse Data (BSc), Gamo Gofa Zone Health Department, MPH student at Gondar University, works on the birth and death registries.

Meseret Girma (BSc), Arba Minch University, MPH student at Gondar University, works on the health institution.

Professor Bernt Lindtjørn, UoB:  Coordinator and main supervisor

Professor Ole Frithjof Norheim, UoB, co-supervisor

Deaths from maternal causes represent the leading cause of deaths among women of reproductive age in Ethiopia. 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 (CEOC), and these services should be available to and used by the pregnant women.

The vision of the Reducing Maternal Mortality project is to improve maternal health and make large decline in maternal mortality. The target population for this project are pregnant women in south-west Ethiopia (se map).

Training of Health Officers

A major problem in rural Ethiopia is the lack of trained health personnel. Our project represents the first attempt train non-clinician physicians on a larger scale. We therefore expect to learn important lessons from this work, that later can be expanded to other regions in Ethiopia.

During the fist six months of 2009, ten health officers, ten anaesthetic nurses and ten scrub nurses received training at Arba Minch Hospital.

Curriculum for training in Emergency Obstetrics and Surgery

The AMH- Curriculum in Emergency Obstetrics and Surgeryshows an outline of the aim and curriculum of our training programme.

The first batch of four health officers has now completed six months of training. The table shows the average number of operations done during the training and follow-up period:

Review of operations

We are continously reviewing the operations done by the staff training under our programme. Please read the updated report here (November 24, 2009).

Some lessons learned

Over the next moths we shall also post some of the lessons learned from our training programme.

The Project ”Reducing Maternal Mortality” in south-west Ethiopia is a local effort to reduce maternal and neonatal deaths.

The project is run by the local Ministry of Health with support from a Norwegian NGO (Norwegian Lutheran Mission). The project started in 2008. The map shows the institutions carrying out Emergency Obstetric Care.

The aim of the work is to reduce maternal deaths, reduce deaths among newborns, and increase the number of deliveries at institutions. The 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.

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 research on HIV epidemiology addresses three areas:

• To study the epidemiology of HIV infection among young adults in rural Etiopia
• To review the impact on the HIV epidemic in Ethiopia
• To study the clinical features of HIV infection, and its association on co-infection with tuberculosis

Epidemiology of HIV infection among young adults:

Molla, M, Berhane, Y and Lindtjørn B. Perception of Ethiopian Youth regarding Their Risk of HIV: A Community-based Study among Youth in Predominately Rural Butajira. Ethiopian Journal of Reproductive Health, 2009, 3(3): 44:51

Molla M, Byass, P: Berhane Y, Lindtjørn B. Mortality decreases among young adults in south-central Ethiopia. Ethiop J Hlth Dev 2008; 22: 218-225.

Molla M, Berhane Y, Lindtjørn B. Traditional values of virginity and sexual behaviour in rural Ethiopian youth: results from a cross-sectional study. BMC Public Health. 2008;8:9.

Mitike Molla, Maria Emmelin, Yemane Berhane, and Bernt Lindtjørn. Youth in rural Ethiopia hesitate to seek health services for sexually transmitted infections: A mixed method research in Butajira, Central Ethiopia. African Journal of AIDS Research 2009, 8(2): 135–146

Datiko DG, Yassin MA, Chekol LT, Kabeto LE, Lindtjørn B. The rate of TB-HIV co-infection depends on the prevalence of HIV infection in a community. BMC Public Health. 2008;8:266.

Kloos H and Lindtjørn B. The HIV/aids epidemic in a least developed country: Ethiopia. Human Ecology Review, 2007; 14 (1): 39 – 55.

Kloos H, Wuhib T, Haile Mariam D and Lindtjørn B. HIV/AIDS in Ethiopia: Prevention and Control, with an Emphasis on the Community. Ethiop J Hlth Dev, 2003, 17 (Special Issue): 3-31.

Clinical features and HIV and tuberculosis co-infection

Jerene D, Naess A, Lindtjørn B. Antiretroviral therapy at a district hospital in Ethiopia prevents death and tuberculosis in a cohort of HIV patients. AIDS Res Ther. 2006;3:10.

Demissie M, Lemma E, Gebeyehu M and Lindtjørn B. Sensitivity to anti TB drugs in HIV positive and negative TB patients. Scan J Infect Dis 2001; 33: 914-919.

Demissie M, Lindtjørn B and Tegbaru B. Human Immunodeficiency Virus infection in tuberculosis patients in Ethiopia. Ethiop J Hlth Dev 2000; 14(3): 277-282.

Madebo T, Nysæter G, Lindtjørn B. HIV infection and malnutrition change the clinical and radiological features of pulmonary tuberculosis. Scand J Inf Dis. 1997;29:355-9.

The Arba Minch Hospital HIV Cohort Study

This cohort study, which started in 2002, is Arba Minch Hospital in south Ethiopia. This public hospital is located 500 Km south of Addis Ababa. The hospital serves a population of about 1.5 million in the Gamo Gofa Zone of the Southern Nations’, Nationalities’, and Peoples’ Regional State.

Registration of patients into HIV care started in January 2003 (AMH HIV cohort). ART started in August 2003 with technical support from the University of Bergen in Norway.

In the AMH HIV Cohort we include all patients registered at the ART clinic. We test, treat and follow patients according to the Ethiopian treatment guidelines. HIV positive patients with WHO stage I-IV are evaluated for treatment. During the first years, patients in stage I and II, received treatment if they had a total lymphocyte count (TLC) of less than 1200/mm³ or CD4 count of less than 200cells/ mm³. Since 2006, we started treatment with CD4 count less than 350 cells/ mm3 for WHO stage III patients. Patients with WHO stage IV disease received treatment irrespective of the TLC or CD4 results.

Following HIV testing and counselling and after recording basic socio-demographic data, a doctor examines all HIV infected patients. Following adherence counselling, we start treatment on eligible patients willing to be treated. We record all patient information using standardized national intake forms and registers in a database.

During the early phase of ART in Ethiopia we used generic combinations of stavudine (d4T), lamivudine (3TC), nevirapine (NVP), zidovudine (ZDV/AZT), and Efavirenz (EFV). Later, we included Tenofovir (TDF). Second-line drugs include Didanosine (DDI), Abacavir (ABC), TDF, and ZDV (if not used as first line regimen), Ritonavir (RTV), Lopinavir (LPV/r), Nelfinavir (NVR), and Indinavir (INV).

This cohort earlier reported on the first documentation on ART use in Ethiopia (1-3), and showed that ART improved survival and reduced sickness among people living with HIV. However, compared with patients from well-resourced settings, patients have higher early mortality rates (4). Although we documented declines in opportunistic infections (OIs) and tuberculosis,  high TB incidence among patients receiving ART remains a challenge.

Based on data from the same cohort, we documented the costs of an ART programme, and showed that ART is cost-effective in a district hospital setting in Ethiopia (5, 6).

Currently the cohort contains about 2500 patients, and our latest study (7) shows that patients over the last years started to present at earlier stages of their illness, and death has decreased among adult HIV patients visiting Arba Minch Hospital. However, many patients were lost from pre-treatment follow-up. Early treatment start contributed to improved survival. We advise to develop new tools for both pre-ART and on-ART patient retention mechanisms.

New Cohort studies

We also plan to start similar studies at other hospitals and health centres in Ethiopia. These studies are planned in Sidama.

References

1. Jerene D, Lindtjorn B. Disease Progression Among Untreated HIV-Infected Patients in South Ethiopia: Implications for Patient Care. J Int AIDS Soc. 2005;7(3):66.

2. Jerene D, Naess A, Lindtjorn B. Antiretroviral therapy at a district hospital in Ethiopia prevents death and tuberculosis in a cohort of HIV patients. AIDS Res Ther. 2006;3:10.

3. Jerene D, Endale A, Lindtjørn B. Acceptability of HIV counselling and testing among tuberculosis patients in south Ethiopia. BMC International Health and Human Rights. 2007 Jan 1.

4. Jerene D, Endale A, Hailu Y, Lindtjørn B. Predictors of early death in a cohort of Ethiopian patients treated with HAART. BMC Infectious Diseases. 2006;6:136.

5. Bikilla AD, Jerene D, Robberstad B, Lindtjorn B. Cost estimates of HIV care and treatment with and without anti-retroviral therapy at Arba Minch Hospital in southern Ethiopia. Cost Eff Resour Alloc. 2009;7:6.

6. Bikilla AD, Jerene D, Robberstad B, Lindtjørn B. Cost-effectiveness of anti-retroviral therapy at a district hospital in southern Ethiopia. Cost Eff Resour Alloc. 2009 Jul 17;7(1):13.

7. Mulissa Z, Jerene D, and Lindtjørn B. 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): e13268. doi:10.1371/journal.pone.0013268