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  Our results (unpublished) show that maternal deaths have since 2008 been reduced by 2/3.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.

New master thesis on patient satisfaction at delivery services

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

Maternal and Neonatal Mortality in South-West Ethiopia

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

Introduction  Ethiopia has achieved the fourth Millennium Development Goal by reducing under 5 mortality. Nevertheless, there are challenges in reducing maternal and neonatal mortality. The aim of this study was to estimate maternal and neonatal mortality and the socio-economic inequalities of these mortalities in rural south-west Ethiopia.

Methods  We visited and enumerated all households but collected data from those that reported pregnancy and birth outcomes in the last five years in 15 of the 30 rural kebeles in Bonke woreda, Gamo Gofa, south-west Ethiopia. The primary outcomes were maternal and neonatal mortality and a secondary outcome was the rate of institutional delivery.

Results  We found 11,762 births in 6572 households; 11,536 live and 226 stillbirths. There were 49 maternal deaths; yielding a maternal mortality ratio of 425 per 100,000 live births (95% CI:318–556). The poorest households had greater MMR compared to richest (550 vs 239 per 100,000 live births). However, the socio-economic factors examined did not have statistically significant association with maternal mortality. There were 308 neonatal deaths; resulting in a neonatal mortality ratio of 27 per 1000 live births (95% CI: 24–30). Neonatal mortality was greater in households in the poorest quartile compared to the richest; adjusted OR (AOR): 2.62 (95% CI: 1.65–4.15), headed by illiterates compared to better educated; AOR: 3.54 (95% CI: 1.11–11.30), far from road (≥6 km) compared to within 5 km; AOR: 2.40 (95% CI: 1.56–3.69), that had three or more births in five years compared to two or less; AOR: 3.22 (95% CI: 2.45–4.22). Households with maternal mortality had an increased risk of stillbirths; OR: 11.6 (95% CI: 6.00–22.7), and neonatal deaths; OR: 7.2 (95% CI: 3.6–14.3). Institutional delivery was only 3.7%.

Conclusion  High mortality with socio-economic inequality and low institutional delivery highlight the importance of strengthening obstetric interventions in rural south-west Ethiopia.

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.