Reducing maternal deaths in Ethiopia: Results of an intervention programme in Southwest Ethiopia

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 nonclinical 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.

This implementation study aimed at reducing maternal deaths analyses the outcomes of interventions done in three of the districts (locally called woreda) in Southwest Ethiopia (the Arba Minch Zuria, Bonke and Dirashe woredas), which had a monitoring system to measure maternal deaths. It was done during the first years of the Ethiopian Health Sector Strategic plan (2010–2015), which emphasized improving maternal and neonatal health [13]. The new Ethiopian health tier system consists of primary level health-care units (primary hospitals that serve a population of 60,000 to 100,000, health centres that serve a population of 15,000 to 25,000 and health posts that serve a population of 3,000 to 5,000 people), as well as secondary level health care including a general hospital (catchment area of 1,000,000 to 1,500,000 people) and tertiary level specialized hospitals, which serve 3.5–5 million people [14]. Most often, the primary health-care unit consists of a health centre and five satellite health posts. Health posts serve as treatment places and are found in kebeles with an average population of 5,000 people. A health post is staffed by HEWs, and they work on health promotion and disease prevention through regular home visits in their catchment area [14, 15]. In addition, they give a prioritized follow-up to households with pregnant women, new-born babies and sick people. HEWs also provide antenatal examinations and delivery services, both at home and health posts. In addition, five to 10 laywomen, known as volunteer health promoters, assist the HEWs, and in 2013 approximately 38,000 health extension workers served villages (kebeles) in the country. Health centres provide curative and preventive services for approximately 25,000 people, with a staff composition of health officers (people with four-year clinical and preventive health education at a university), nurses, midwives, laboratory technicians and pharmacy technicians. Hospitals have medical doctors, in addition to other professionals with the specialty depending on the status of the hospital. In our area of working, we used the skills of these workers to register births and maternal deaths, and also to monitor whether there was a decline in maternal and neonatal deaths during our intervention [16]. During this period, the government also discussed the need to set up vital registration systems, including birth registration and the Central Statistical Agency suggested, thereby that the HEWs found in all local communities could be responsible for such registration. We therefore set up, field tested and implemented a pilot scheme to register births and neonatal deaths [8, 16]. Simultaneously, the WHO started with the maternal death review and maternal death surveillance and response guidelines as part of an international effort to monitor the work to reduce maternal deaths [17]. The “Maternal Death Surveillance and Response” was also started in Ethiopia, but was implemented in our study area fairly late [14]. This intervention study was done in the three woredas (districts) of Arba Minch Zuria, Bonke and Dirashe) in two zones (the Gamo Gofa and Segen Areas Peoples’ Zones) in South-west Ethiopia in the Southern Nations, Nationalities and Peoples' Region (see Fig 1). Our intervention area represents three climatic areas (cold, temperate and hot) and most of the people live in the highlands 2,000 metres above sea level and practice subsistence farming. There are few all-weather roads, and many people live in areas without access to roads. SNNRP: Southern Nations, Nationalities and Peoples' Region. The population of the Gamo Gofa Zone was roughly 1.75 million people in 2010. The capital of the zone is Arba Minch Town, which is located approximately 500 km from Addis Ababa. Moreover, the population of the Segen Area Peoples’ Zone was 640,000 people in 2010. In 2010, about 170,000 people lived in Bonke. This woreda (district) had no hospital providing CEmOC during the study; hence, people in need of such services had to travel to the nearest hospital, the Arba Minch Hospital, located approximately 100 kilometres from Bonke. In late 2014, a health centre in this area started to provide the population with comprehensive emergency obstetric care. In addition, the Ministry of Health started to build a hospital in the area. At the time of our study, approximately 380,000 people lived in the Arba Minch Zuria Woreda, and the district had one large hospital. The larger parts of the population in this district live in the Gamo highlands, far from this hospital. The people living here have limited road access for comprehensive delivery services. In 2010, roughly 142,000 people lived in Dirashe. This district is served by Gidole Hospital, which has a well-functioning maternity waiting area where mothers with high-risk pregnancies are referred to- and observed until delivery [18]. This implementation study used the following outcome measures: maternal deaths measured as the maternal mortality ratio. The secondary outcomes were the proportion of skilled birth attendance, proportion of institutional deliveries, referrals to health posts, health centres or hospitals. We also measured the use of antenatal control. Explanatory variables included distance to institution, literacy of `both the husband and of delivering mothers, history of previous pregnancies and deliveries, and whether any illness had occurred during the pregnancy. Because the interventions we used are believed to be effective [19], we considered it unethical to introduce a control area without access to such interventions. Our study analyses trended toward the use of interventions and simultaneously occurring improvements in outcome measures, especially maternal mortality. Together with the Ministry of Health, we designed a project to strengthen the health-care system. A particular emphasis was given to upgrading existing institutions so that they could carry out BEmOC and CEmOC. These 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. The aim of the project was to assure that each health facility had obstetric services available 24 hours a day and seven days a week, and were staffed by skilled health professionals. An Emergency Obstetric Care (EmOC) facility refers to whether or not an institution is fully functioning as a basic (BEmOC) or comprehensive (CEmOC) facility [4]. We defined the functioning by nine signal functions: administering parenteral antibiotics, administering parenteral oxytocic drugs, administering parenteral sedatives, manual removal of the placenta, removal of retained products of conception, assisted vaginal delivery (vacuum or forceps delivery) (BEmOC). Institutions, which in addition to these signal functions could do caesarean sections and have a blood transfusion service, were defined as CEmOC facilities. At the start of our intervention, we conducted a review of the basic signal functions at three hospitals and 63 health centres in the Gamo Gofa Zone [3]. Our study showed that the availability, use and quality of BEmOC and CEmOC facilities fell below the accepted WHO standards [3]. The results of this mapping was used to strengthen the institutions, and a study done some years after this mapping showed that institutions had functional comprehensive or basic emergency services [20]. Each of the institutions were regularly supervised, at least once every quarter, to monitor the progress of the work. A specific emphasis was given to ensure that each institution practised the signal functions listed above, and to discuss how to deal with problematic deliveries and operations. We actively used the delivery and operations registration books to conduct systematic audits of the work the previous months, and thus identify challenges and improve the services. Consequently, the supervisory visits also had the form of audits to monitor the work at the delivery units. Every delivery unit at an institution was led by a case-management team, and the supervisory visits took place at least once every quarter. In case unexpected incidences or complications had occurred, we evaluated events that had taken place using a no-blame culture [21, 22]. And events occurring at one institution were shared with staff from the other institutions, thereby promoting a continuous learning attitude among the staff [23]. Our experiences agree with the experience from countries such as the UK, which show that unit-based incident reporting, instead of institutional reporting systems, forms a better learning environment to improve services [24]. Table 1 outlines the provinces (woreda) we worked in, and describes the type of institutions and the work that they are supposed to do. Each health centre is responsible for at least five rural villages (kebeles). Two health extension workers serve each kebele, and each of the health extension workers received specific training on safe and clean delivery, and about when to refer patients to health centres or hospitals. Note—BEmOC: Basic Emergency Obstetric Care; CEmOC: Comprehensive Emergency Obstetric Care. Parallel to the health interventions, we also set up a monitoring system to evaluate whether maternal mortality declined, if the mothers were referred or not, where the babies were delivered and who helped the mother during the delivery. We therefore set up a population-based birth registration system, and this has been validated and described in details [8]. The validation included a comparison of community-based birth registration with the sisterhood method, cross-sectional community surveys and with the institutional-based registration of maternal deaths [16]. Our conclusion is that the birth registration done by health extension workers provides a valid, community-based measurement of maternal deaths [16]. In 2009, during the second year of our work, we evaluated the results of the performance of non-clinical physicians and general practitioners doing Caesarean sections (C/S). This was done by prospectively recording operations done at the government hospitals and health centres. We reviewed the results of the health officers (non-clinical physicians with a BSc degree) and general practitioners who had been trained through this intervention programme at the Arba Minch Hospital. The assessment was done after they had completed a four-month training period. We studied all women undergoing a Caesarean section during the study period, and we recorded information on admission diagnosis, reason for surgery, preoperative conditions, with the outcome measures including neonatal and maternal conditions, post-operative complications and mortality. During 2009, we collected data from 207 consecutive obstetric surgeries in four district health institutions in southern Ethiopia. These operations were done by general practitioners (38 operations; 18%) or health officers (169 operations, 82%). The main indications for surgery were cephalopelvic disproportion or obstructed labour (76 patients; 37%), foetal distress (43 patients; 21%), failure to progress (22 patients; 11%), previous C/S (13 patients; 6%), antepartum haemorrhage (12 patients; 6%), whereas the remaining operations were for uterus rupture, cord prolapse, breech in primigravidae and eclampsia. A Caesarean section (C/S) was done on 199 operations, and eight operations were for uterine rupture. Two mothers (0.9%) died during their operation or during their stay at the hospital. There were 23 (11%) stillbirths, and five children (2%) died during the stay at the hospital. The rate of stillbirths varied among the hospitals, with the highest rate being at the newly started hospital in Saula (17 of 23 stillbirths and three out of five early neonatal deaths). Intraoperative complications occurred in five patients. Three of them were serious. and one re-operation was done because of bleeding. Three patients needed post-operative blood transfusions, and six patients had post-operative infections. Lastly, the mean duration of stay was seven days after operation. This initial assessment showed that Caesarean sections can safely be done in rural areas of southern Ethiopia. The post-operative mortality was approximately 1%, which is acceptable by WHO targets [25]. We used the WHO-ICD-10 definition and classification of maternal deaths. Thus, if a mother died during pregnancy, during delivery, or within 42 days after the delivery or termination of pregnancy, we classified this death as a maternal death [26]. However, if the women died of an accident or suicide we did not label it as a maternal death. We also used the WHO maternal death review manual of 2004 to classify the possible causes of deaths [17]. Since this work was done in a rural setting with limited access to health institutions, the cause of death was based on our history taking of the symptoms such as convulsions, fevers or excessive bleeding due to haemorrhage. The setup of the birth registration system has been previously described [8]. In brief, we trained all health extension workers before starting the registration, and we employed supervisors who were trained nurses to visit each of the health posts. The data were entered in a printed registry book at each health post by the health extension workers. Each month, nursing supervisors visited the health post, checking the registry for completeness, supervising the health extension worker and taking a copy of the registry book to the project office. Our birth registration contains about 3½ years of valid data. In late 2013, the birth registries were transferred to the local government system. This caused an interruption that resulted in data that could not be fully quality assured, so we have therefore only included data in which supervisory nurses checked the quality of the birth registration. The availability of Emergency Obstetric Care is important to help avoid maternal deaths due to life-threatening complications [27]. The lack of transportation is a known barrier to the access of EmOC facilities, especially in rural areas [28]. In our study, we recorded both the type of road available close to the patient homes, assuming that road type is also associated with the availability of access to public transportation. We also recorded the walking time to the nearest institution in minutes. Unfortunately, the walking time in minutes showed large variances for the same locations; we therefore did not use it in our study. We used road access as a proxy measure for access to transportation, as has been validated by others [29]. Data were then entered into a computer using SPSS software (SPSS Inc., Chicago. IL), and the data were subsequently checked for completeness and errors, and the paper forms could be returned to the health post for further checks. For the analysis, we calculated proportions, incidence rates and odds ratios, and used logistic regression for multivariate analysis. This is an implementation study, and the work done was a part of the routine work of the hospitals, health institutions and health extension workers in the area. For the research part, the Institution Review Board for Health Research of Southern Nations Nationalities and Peoples’ Regional State (SNNPRS) in Ethiopia, and the Regional Committee for Health Research Ethics of North Norway (REK Nord), approved the study.

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• lindtjørn, bernt
• mitiku, demissew
• zidda, zillo
• yaya, yaliso