Reducing maternal deaths in Southwest Ethiopia

Lindtjørn B, Mitiku D, Zidda Z, Yaya Y (2017) Reducing Maternal Deaths in Ethiopia: Results of an Intervention Programme in Southwest Ethiopia. PLoS 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.

Yalio Yaya defends his PhD thesis

Yaliso-front-pageThe overall objective of the PhD thesis is to measure and compare maternal and neonatal mortality and obstetric services through community- and facility-based methods in southern Ethiopia. Yaliso Yaya used four different methods to measure maternal mortality:

  1. A prospective community-based birth registry managed by health extension workers in 75 rural villages in three districts in south Ethiopia (population 421 639)
  2. A household survey conducted in 6 572 households in 15 randomly selected rural villages in the district of Bonke, with questions about pregnancy and birth outcomes in the last five years
  3. A household survey among 8 503 adult siblings using the sisterhood method
  4. A facility-based review of records in all 63 health centres and three hospitals in Gamo Gofa zone.

Neonatal mortality was measured with the second method, and emergency obstetric services were assessed through the facility-based review.

The thesis is based on a thorough and systematic registration of adverse events during several years, using multiple methods. This allows validation of estimates, and it presents detailed and precise information about maternal mortality rates from rural south Ethiopia.

A special focus of the work is on the finding that community based health workers (Health Extension Workers) can be used to generate maternal mortality data, thus alleviating the chronic problem of unavailability of valid and timely mortality data.

The PhD thesis can be downloaded here.

Improving birth and pregnancy-outcomes through registries in southern Ethiopia

Recently, Yaliso Yaya, PhD candidate at  The Centre for International Health wrote the following post as part of the The Maternal Health Task Force series Translating Research into Practice Series

Ethiopia ambulances maternal mortality

Motorcycle ambulances have been useful for transporting mothers with complications to health facilities. The message in Amharic reads “A mother should not die while giving life.” (Photo: Demissew Mitiku).

Unfortunately, there is still limited information to oversee maternal and newborn mortality interventions in low-income countries. Developing countries lack vital registrations that are present in high-income countries. Because of the shortage of such essential information, translating policy into action and monitoring programmes to reduce maternal and neonatal deaths is difficult.

The new Sustainable Development Goals divide countries into three groups where the maternal mortality ratio (MMR) is greater than 400, between 100 and 400, and less than 100 based on the ratio in 2010. Such a grouping is necessary because different ratios may determine different intervention strategies. Unfortunately, for many countries there is a controversy over the level of the MMR. If we use Ethiopia as an example, a UN estimate of MMR in 2010 is 350 per 100,000 live births, whereas the DHS estimated it to be 676 for the same year.

As a follow-up to our paperMaternal and Neonatal Mortality in South-West Ethiopia: Estimates and Socio-Economic Inequality, we developed, validated, and used community based birth registration in a population of about half a million people in four woredas, or districts, in rural southern Ethiopia. We aimed to estimate maternal mortality rates and to monitor progress in reducing deaths. The most important lesson we learnt, that may be applicable in similar settings in Ethiopia and in Africa, is that it is possible to obtain high-coverage birth registration and measure maternal mortality in rural communities with trained community health workers.

In southern Ethiopia, the MMR was high and most births and maternal deaths occurred at home. The MMR was about 500 per 100,000 live births in 2010, and data from 2014 show that this ratio may have been reduced by about 60%.

We also registered that when women’s access to comprehensive and basic obstetric services improves, a birth registration system can document important societal changes:

  1. Significantly increased institutional delivery rates
  2. Decreased use of traditional birth attendants
  3. More than half of women who deliver attend three or more antenatal care visits

In our experience, it is possible to register most births in rural Ethiopian communities using the health extension workers. However, we advise that a birth registry should be expanded to include registration of pregnancies as well as pregnancy outcomes. Such a system could provide the community health workers with a new tool to actively follow up pregnant women and ensure proper antenatal controls and referrals to institutions. It could also help in monitoring neonatal heath and be a tool to provide essential services to women in the weeks after birth.

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.

Publications

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.

Publications on Reducing Maternal Deaths

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

Girma M, Yaya Y, Gebrehanna E, Berhane Y, Lindtjørn 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.

Yaya Y, Eide KT, Norheim OF, Lindtjørn B. Maternal and neonatal mortality in south-west Ethiopia: Estimates and socio-economic inequality. Under review in PLoS ONE (2014)

Yaya Y, Data T, and Lindtjørn B. Maternal mortality in rural Ethiopia: Feasibility of community-based birth registration by the Health Extension Workers (Manuscript submitted 2014).

Master Degree Thesis

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.

Ongoing Master degree research projects:

Rahel Tesfaye. Assessment Of Quality Of Intrapartum Care In   Gamo-Gofa Zone, SNNRP, Ethiopia. Arba Minch University, expected to finish in 2014.

Demeke Damota. Factors affecting institutional delivery in Arba Minch Town (Gamo Gofa Zone). Expected to finish in 2014.

Zillo Zidda. Topic: Results of Caesarean sections done in the RMM project.  Arba Minch University, expected to finish in 2015.

Demissew Mitike. Topic: Increasing institutional delivery rates in Seggen Zone.  Arba Minch University, expected to finish in 2015.

Planned publications:

Reducing maternal mortality in South Ethiopia: Results of a decentralised health care model (2008 – 2013): 2014 Manuscript.

Preliminary reports:

Lindtjørn B. Caesarean sections done by health officers in south-west Ethiopia. See Report (26. November 2009).

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.

Background
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.

Methods
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.

Results
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%).

Conclusion
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.

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.

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.