Publications on Reducing Maternal Deaths

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.

Lindtjørn B, Mitiku D, Zidda Z, Yaya Y (2017) Reducing Maternal Deaths in Ethiopia: Results of an Intervention Programme in Southwest EthiopiaPLoS ONE 12(1): e0169304. doi:10.1371/journal.pone.0169304

Background  In a large population in Southwest Ethiopia (population 700,000), we carried out a complex set of interventions with the aim of reducing maternal mortality. This study evaluated the effects of several coordinated interventions to help improve effective coverage and reduce maternal deaths. Together with the Ministry of Health in Ethiopia, we designed a project to strengthen the health-care system. A particular emphasis was given to upgrade existing institutions so that they could carry out Basic (BEmOC) and Comprehensive Emergency Obstetric Care (CEmOC). Health institutions were upgraded by training non-clinical physicians and midwives by providing the institutions with essential and basic equipment, and by regular monitoring and supervision by staff competent in emergency obstetric work.

Results  In this implementation study, the maternal mortality ratio (MMR) was the primary outcome. The study was carried out from 2010 to 2013 in three districts, and we registered 38,312 births. The MMR declined by 64% during the intervention period from 477 to 219 deaths per 100,000 live births (OR 0.46; 95% CI 0.24–0.88). The decline in MMR was higher for the districts with CEmOC, while the mean number of antenatal visits for each woman was 2.6 (Inter Quartile Range 2–4). The percentage of pregnant women who attended four or more antenatal controls increased by 20%, with the number of women who delivered at home declining by 10.5% (P<0.001). Similarly, the number of deliveries at health posts, health centres and hospitals increased, and we observed a decline in the use of traditional birth attendants. Households living near to all-weather roads had lower maternal mortality rates (MMR 220) compared with households without roads (MMR 598; OR 2.72 (95% CI 1.61–4.61)).

Conclusions  Our results show that it is possible to achieve substantial reductions in maternal mortality rates over a short period of time if the effective coverage of well-known interventions is implemented.

Tesfaye R, Worku A, Godana W, Lindtjorn B: Client Satisfaction with Delivery Care Service and Associated Factors in the Public Health Facilities of Gamo Gofa Zone, Southwest Ethiopia:In a Resource Limited Setting. Obstetrics and Gynecology International 2016, 2016:1-7.

Yaya Y, Data T, Lindtjørn B (2015) Maternal Mortality in Rural South Ethiopia: Outcomes of Community-Based Birth Registration by Health Extension WorkersPLoS ONE 10(3): e0119321. doi: 10.1371/journal.pone.0119321

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 EthiopiaBMC 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.

PhD thesis:

Yaya Y. Maternal and neonatal mortality in rural south Ethiopia: Comparing mortality measurements and assessing obstetric care [PhD]. Bergen: University of Bergen; 2015.

Master Degree (MPH) Thesis

Zillo Zidda. Maternal Complication and Associated Factors among Women who gave birth by Caesarian Section Delivery at Gamo Goffa Zone and Basketo Special Woreda, Southern Ethiopia. Arba Minch University, MPH. 2015.

Demissew Mitike. Maternal referral compliance for delivery service and associated factors in Dirashe Woreda, Southern Ethiopia. MPH. Arba Minch University, 2015.

Rahel Tesfaye. Assessment Of Quality Of Intrapartum Care In   Gamo-Gofa Zone, SNNRP, Ethiopia. 2014. Arba Minch University and Addis Continental Institute of Public Health.

Demeke Damota. Factors affecting institutional delivery in Arba Minch Town (Gamo Gofa Zone). 2014. Arba Minch University and Addis Continental Institute of Public Health.

Tadesse Data. Quality check household survey on community birth registry in Bonke woreda in Gamu Gofa Zone in South-west Ethiopia. 2011. Addis Continental Institute of Public Health and University of Gondar.

Meseret Girma Abate. Assessment of availability and utilisation of Emergency Obstetric Care Services In Gamo Gofa Zone, SNNRP, Ethiopia. 2011. Addis Continental Institute of Public Health and University of Gondar.

Abstracts Master degree Thesis

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.

Background Ensuring patient satisfaction is an important means of secondary prevention of maternal mortality. Satisfied women may be more likely to follow to health providers’ recommendations. And, studying patient satisfaction can help to improve services, and reduce costs. However, so far there few reports on client satisfaction on delivery care from developing countries. This study presents findings from a multi-dimensional study of client satisfaction from the Gamo Gofa Zone in South-West Ethiopia.

Objective The aim of this study was to assess how satisfied clients using delivery services at public health facilities are Gamo Gofa zone in South-West Ethiopia.

Methods Using exit interviews and we did a facility based cross sectional study in December 2013 and January 2014. We measured client satisfaction using a survey adopted from the Donabedian quality assessment framework. We randomly sampled 13 of 66 institutions in Gamo Gofa. The number of delivering mothers in each health institution was based on proportional to size allocation. We used logistic regression to determine predictors of client satisfaction.

Results Most of mothers (79%; 95% CI; 75-82%) were satisfied with delivery care. The presence of support persons during child birth improved satisfaction (AOR=8.19 95% CI; 3.49-18.8). ), as were women who delivered with caesarean section (AOR 2.99; 95% CI; 1.17 -7.66). However, client satisfaction was reduced if the women had to pay for the services (AOR=0.13 95%CI; 0.06-0.29). Women attending hospitals were less satisfied (69%) than women attending health centres (94%). The proportion of women who complained about an unfriendly attitude from health workers was higher in the hospitals.

Conclusions The study shows that that overall satisfaction level good, but there is room for improvements. More emphasis should be to have women friendly care, especially at the hospitals.

Tadesse Data. Quality check household survey on community birth registry in Bonke woreda in Gamu Gofa Zone in South-west Ethiopia. 2011. 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.

Meseret Girma Abate. Assessment of availability and utilisation of Emergency Obstetric Care Services In Gamo Gofa Zone, SNNRP, Ethiopia. 2011. Addis Continental Institute of Public Health and University of Gondar.

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.

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