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.

Stillbirths in Ethiopia

A stillbirth occurs when a foetus dies in the uterus and when foetal death occurs after 20 weeks gestation or the foetus weighs more than 400 grams. We use the term to distinguish it from live birth or miscarriage. Most stillbirths occur in full term pregnancies.

The Lancet recently presented a series of articles on stillbirths. We can confirm from our studies from south Ethiopia that stillbirths represent a huge problem. About 5% of all hospital births are stillbirths. And, in our birth registry data, about 1.4 per cent of registered births are labelled as stillbirths. Such figures are uncertain, and some neonatal deaths might be misclassified as stillbirths.

Results from our studies in Ethiopia demand that we need to address this issue. What are the causes? Can we do anything to reduce stillbirths in settings such as rural south-west Ethiopia? We now plan to recruit a new PhD student to investigate how stillbirths can be reduced in southwest Ethiopia.

 

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.

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.

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.

30,000 women have an untreated vesicovaginal fistula

In Ethiopia about 30,000 women have an untreated vesicovaginal fistula. Most often this is the result of complications of neglected, prolonged or obstructed labour.

At our new Fistula Unit in Arba Minch we collaborate with the Fistula Hospital in Addis Ababa in Ethiopia. This hospital in Addis Ababa is dedicated only to the care of women with obstetric fistulae, and treating other physical and social injuries.

In their experience, this vesicovaginal fistula often results in other injuries. More than half of the patients will be divorced and excluded from religious activities, their home, public transport and health institutions. Patients with fistulas have more than a ‘hole’ between the bladder and vagina, and often have physical, psychological and social problems, stress and urge urinary incontinence, hydronephrosis, renal failure, rectovaginal fistulae, secondary infertility, vaginal scarring and damage to the nerves (foot drop).

You can read a review of the experiences from the Fistula Hospital in Addis Ababa in a paper in by Professor Gordon Williams in The Surgeon (February 2007 Vol 5 No 1).