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Introduction Rural communities in low-income countries lack vital registrations to track birth outcomes. We aimed to examine the feasibility of community-based birth registration and measure maternal mortality ratio (MMR) in rural south Ethiopia. Methods In 2010, health extension workers (HEWs) registered births and maternal deaths among 421,639 people in three districts (Derashe, Bonke, and Arba Minch Zuria). One nurse-supervisor per district provided administrative and technical support to HEWs. The primary outcomes were the feasibility of registration of a high proportion of births and measuring MMR. The secondary outcome was the proportion of skilled birth attendance. We validated the completeness of the registry and the MMR by conducting a house-to-house survey in 15 randomly selected villages in Bonke. Results We registered 10,987 births (81-4% of expected 13,492 births) with annual crude birth rate of 32 per 1,000 population. The validation study showed that, of 2,401 births occurred in the surveyed households within eight months of the initiation of the registry, 71-6% (1,718) were registered with similar MMRs (474 vs. 439) between the registered and unregistered births. Overall, we recorded 53 maternal deaths; MMR was 489 per 100,000 live births and 83% (44 of 53 maternal deaths) occurred at home. Ninety percent (9,863 births) were at home, 4% (430) at health posts, 2-5% (282) at health centres, and 3-5% (412) in hospitals. MMR increased if: the male partners were illiterate (609 vs. 346; p= 0-051) and the villages had no road access (946 vs. 410; p= 0-039). The validation helped to increase the registration coverage by 10% through feedback discussions. Conclusion It is possible to obtain a high-coverage birth registration and measure MMR in rural communities where a functional system of community health workers exists. The MMR was high in rural south Ethiopia and most births and maternal deaths occurred at home.
The Ethical Review Committee for the Health Research of Southern Nations Nationalities and Peoples’ Regional State (SNNPRS) Health Bureau in Ethiopia, and the Regional Committee for Health Research Ethics of North Norway (REK Nord) in Norway approved the study. Birth and birth-outcome registration is part of the routine work of the HEWs in Ethiopia, which is acknowledged by the government. We systematized the registry by preparing a standardized format and providing technical support. Personal identifiers were removed from the stored data used for research. We obtained informed verbal consent from respondents for the validation study of house-to-house survey and the responses were recorded on the questionnaire as “accepted” or “declined” to participate. Written consent was not considered because a large number of the respondents were illiterate and the Ethics Committee approved the verbal consent procedure. The Ethiopian government has autonomous regional states within the Federal Republic. In turn, regional states are subdivided into zones (provinces), Woredas (districts), and Kebeles (villages). A zone is a cluster of 10–15 districts, and a district is a group of 20–50 villages. A Kebele is the lowest administrative structure and is comprised of 1,000–1,500 households. This study was conducted in three districts (Arba Minch Zuria, Bonke, and Derashe) in two zones (Gamo Gofa and Segen Area Peoples’) in the Southern Nations, Nationalities, and Peoples’ Region (SNNPR, Fig. 1). The Gamo Gofa Zone (population = 1,740,828 people in 2010) [18], the centre of which is at Arba Minch, is 505 km from Addis Ababa to the southwest and the Segen Area Peoples’ Zone (636,794 residents in 2010) [18] is 575 km from Addis Ababa. Bonke, with a population of 166,913 people in 2010, had no hospital providing comprehensive emergency obstetric care at the time of the study. The nearest such service was at Arba Minch Hospital, which is 50–150 km from the villages of Bonke. Arba Minch Zuria, with a population of 179,785 people, has a hospital, although the largest proportion of the population lives in the highlands far from the hospital and driveable roads. Derashe, with a population of 141,589 has a district hospital in the main town of Gidole, as well as well-functioning maternity waiting homes, traditional thatched huts built in the hospital compound, where mothers with high-risk pregnancies are referred and observed until delivery [19]. Fig. 2 presents the study profile. In 2008, the MMR in Ethiopia was 590 per 100,000 live births (LBs) [9]. Assuming this would be comparable for the study area, we expected there could be a 10% decline in two years resulting in an MMR of 531 (95% CI: 413, 669) per 100,000 LBs in 2010. Thus, we expected 70 maternal deaths in a year (95% CI: 55, 88) out of estimated 13,492 births (13,223 LBs) in a population of 421,639 people. LBs were approximated 98% of all births in the area [20]. To estimate the expected number of births, we used an annual crude birth rate (CBR) of 32 per 1,000 population based on the following two sources of birth rate information: a finding from a household survey in 2010 in one of the study districts (Bonke) [20], and the same estimate by The World Bank of CBR in Ethiopia for 2010 [21]. To identify group differences in the MMR, we assumed the number of maternal deaths amongst births determined above would provide sufficient data. We purposely selected three districts with the number of residents expected to produce the above estimated births and maternal outcomes. The districts were assumed to represent the area in terms of health services, demographics, and road access. In these districts, we included all kebeles (villages), except those where the HEWs were sick or on maternity leave at the time of starting the registration. We used OpenEpi software (Open Source Epidemiologic Statistics for Public Health version 3.01,www.openepi.com) to calculate the sample size. The HEP is a community-based healthcare system with two female HEWs serving a rural village of 1,000–1,500 households. Most of the HEWs have completed a 10th grade education and received one year of general health training. Their work focuses on family health (child vaccinations, family planning, antenatal care, and assisting normal deliveries) and health promotion. HEWs are expected to routinely visit each household in their catchment once a month, prioritizing households with pregnancies, newborns, and sick persons. HEWs are part of the permanent health workforce and receive a monthly salary of 40–50 USD from the government based on their years of service. In addition, 5–10 lay-women known as volunteer health promoters (VHPs), assist the work of HEWs by informing of households with a recent delivery, sick people, and deaths in the sub-villages. We conducted one week training at each woreda centre for HEWs, supervisors, and the district health authorities before the registry started. Supervisors were experienced nurses (one per district), who helped the HEWs in reviewing and classifying deaths, monitoring the quality of data, and transferring the registered information from HEWs to the central data clerk. During the training, we clarified the WHO ICD-10 definition and classification of maternal deaths [22]. Accordingly, if a woman died during ante- or intra-partum periods, or within six weeks after termination of a pregnancy and her pregnancy status was known, her death was considered a maternal death if the death was not because of an accident or incident such as suicide. We also used extractions from the WHO maternal death review (MDR) manual published in 2004 to determine the cause of deaths [15]. As such, diagnosing the cause of death was based on symptomatic approaches such as convulsions attributed to hypertensive disorders, fevers to infections, and excessive bleeding due to haemorrhage. The specific registration and maternal death ascertainment procedure is presented as follows. HEWs visited homes within hours or days after the pregnancy ended depending on the distance and the speed of notification from the sub-village VHPs or families. At the household, HEWs assessed and registered birth and births conditions. The HEWs continued the follow-up until a maternal death was occurred or six-week post-partum. This collection of information was similar to births that occurred at home and in health facilities because all births were available for recording at homes. In addition, in households in which a woman of reproductive age died without giving birth, HEWs critically reviewed the conditions at the time of death to determine the pregnancy status of the deceased and determine the probable cause of death. Husbands or fathers of the baby (FOBs) were primary sources of information for maternal deaths; however, in the cases where obtaining information from the husbands or FOBs was not possible, adult members of the family helped in providing information. HEWs registered the data in printed birth registry books (Fig. 3). The book contained important socio-demographic variables, such as the distance of the village from the nearest health centre and the nearest hospital recognized by the respective district health offices, as well as the type (quality) of road to the village as a general heading information. The actual body of the book rows contained personal background information, such as education of the mother and father and age of the mother. In addition, the woman’s parity, the place of birth, the attendant of birth, the condition of the newborn at birth (alive or stillbirth), the gender of the foetus, and maternal deaths (including the place, cause, and time) were among the variables. Registration was made in duplicate and the first copy was detached and sent to the Research and Training Centre at Arba Minch Hospital, while the second copy remained with the book in the village. Most births were registered within 24 hours of delivery, unless there was a special reason for a delay (births in distant health institutions, where the household was far from the HEW station or HEWs were not informed in a timely manner). Similarly, most maternal deaths were identified immediately. Nevertheless, HEWs made a final follow-up home visit six weeks after birth or abortion when death information was not obtained prior to the stated deadline. The primary outcomes were the coverage of birth registration (percentage registered out of the estimated) and the MMR. The secondary outcome was the proportion of skilled birth attendance, facility deliveries supervised by skilled professionals. To check the validity of the registration eight months after the start of the registration, we conducted a house-to-house survey in 15 of the 30 rural villages in the Bonke. Data collectors who had completed the 12th grade visited every household and searched for a birth or pregnancy outcome since the start of the birth registry. For births already registered in the birth registry, they checked the content (date of birth, date of death, and baby’s gender). The unregistered were recorded and the data were transferred to the registry book. Based on the findings of the validation study, we discussed the feedback with the HEWs and supervisors to improve the coverage of the registration. We entered, checked, and analyzed the registry and validation data using the statistical package for social sciences (SPSS-16) describing the results in tables showing proportions and means. To show the variation in maternal mortality, we used a chi-square test. For the validation study, we produced a descriptive table showing the proportion of births registered and unregistered out of the births found during the validation survey. We made a cross-tabulation for crude analysis to determine the risk of maternal deaths among registered births compared to unregistered and the effect of antenatal follow-up and distance from HEW station on the likelihood of births being registered.
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