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.

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

Active case finding in tuberculosis

ResearchBlogging.orgEven if 36 million patients with tuberculosis were successfully treated, and up to 6 million lives were saved during the past 15 years, tuberculosis remains a major public health problem. More than 9 million cases occur every year.

Unfortunately, only a little more that half of the expected cases are identified yearly and receive proper care. We therefore need novel measures to diagnose, treat, and thus stop transmission of tuberculosis.

Many have previously questioned the role of active case finding in reducing tuberculosis prevalence. Recently, several active case-finding strategies for tuberculosis were tested and proved to be effective, both in urban (Corbett, Bandason et al. 2010) and rural settings (Datiko and Lindtjørn 2009). The Lancet study (Corbett, Bandason et al. 2010) also documented the effect on the prevalence of culture-positive tuberculosis. The study from Ethiopia also showed that active case finding is a cost-effective strategy (Datiko and Lindtjørn 2010).

These studies highlight active case-finding in tuberculosis control efforts, especially in settings where HIV is prevalent and in weak health systems.

Some of the research priorities for countries with weak health systems should include:

  • Evaluate tools for effective active case-finding so it reduces tuberculosis prevalence. To do this we should also set up good records on tuberculosis prevalence, and thus be able to document a future decline in tuberculosis prevalence.
  • We need to develop different models for active case finding in communities. By this, I mean practical tools on how to do this in a local community. We are starting a new research in Ethiopia to develop “tuberculosis suspect registries” in the communities as a tool to identify patients with tuberculosis.
  • In addition, we urgently need fast, accurate, and simple diagnostic test.

And, scaling up active case-finding outside health institutions needs to be paired with increased scientific interest, research investment, and political commitment for high-quality basic and operational research.

Corbett, E., Bandason, T., Duong, T., Dauya, E., Makamure, B., Churchyard, G., Williams, B., Munyati, S., Butterworth, A., & Mason, P. (2010). Comparison of two active case-finding strategies for community-based diagnosis of symptomatic smear-positive tuberculosis and control of infectious tuberculosis in Harare, Zimbabwe (DETECTB): a cluster-randomised trial The Lancet, 376 (9748), 1244-1253 DOI: 10.1016/S0140-6736(10)61425-0

Datiko DG, Lindtjorn B (2009) Health extension workers improve tuberculosis case detection and treatment success in southern Ethiopia: a community randomized trial. PLoS One 4: e5443.

Datiko DG, Lindtjorn B (2010) Cost and cost-effectiveness of smear-positive tuberculosis treatment by Health Extension Workers in Southern Ethiopia: a community randomized trial. PLoS One 5: e9158.

Maternal Mortality in Ethiopia

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.

Specialists and health care for the poor

I recently had a long chat with young general practitioners in south Ethiopia. «Our aim is to become specialist doctors», they said. I replied that most specialists do not return to the rural areas they come from and where they first intended to work in. Their answer was there was a need for specialist in the large city hospitals, and after having endured hardship as General Practitioners and with established families, they found it natural not to return to the rural and poor South Ethiopia.

And the tendency is that general specialists in fields as internal medicine and surgery want to continue training and become subspecialists.

A recent Naturejobs paper discusses the career of PhD graduates. Some PhD graduates end up doing very specific tasks, often in academic institutions. However, through their PhD training they gain valuable general skills that qualify them for more general careers. Industry usually wants highly skilled and trained people with a flexible attitude. The PhD researcher who insists on limiting their work to a narrow area of research specialisation sometimes end as «Research Geek».

In research, as in practical medicine, most of the work is routine, and deals with everyday problems. Specialist gain general skills during their training that they could and should use for the benefit of patients and health problems beyond their narrow specialisation.

A few days ago I was working at the remote Saula Hospital in South-west Ethiopia. During the rounds in the inn-patient ward I realised that many of the seriously sick patients had not been diagnosed properly. A patient with pyomyositis (multiple abscesses) had an underlying leukaemia. A patient with grossly swollen breasts did not have a breast disease, but a severe heart failure. A three-year-old child with fast breathing had been treated for pneumonia, but had severe falciparum malaria infection.

Poor diagnostic work leads to poor treatment and care, and is probably the reason only 10 patients were admitted to Saula Hospital from a population of 800.000 people in its catchment area. Hospitals as Saula needs specialists, but of a kind that is willing to go beyond their own specialisation.

Unfortunately, the international trend, now also affecting developing countries, is to increase specialisation and thus leave a large part of the work to nurses, non-physician clinicians, and to newly educated doctors doing compulsory services in remote hospitals.

Reducing maternal deaths in south-west Ethiopia

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.

2009 report on “Reducing Maternal Mortality Project”

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.b.uib.no/my-research-areas/reproductive-healthproject/reducing-maternal-and-neonatal-mortality/

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

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.

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.