Lifesaving emergency obstetric services are inadequate in south-west Ethiopia: A formidable challenge to reducing maternal mortality in Ethiopia

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. © 2013 Girma et al.; licensee BioMed Central Ltd. The study was conducted in the Gamo Gofa Zone in south-west Ethiopia (see map in Figure 1). Nearly 1.7 million people live in the area, with 90% living in rural communities. The Zone has 15 woredas (districts) and two town administrations, each being directly administratively responsible to the Zone. However, people in the surrounding districts of the towns, as well as the towns themselves, use the health facilities/services/ in these towns. The Zone represents three climatic zones (cold, temperate and hot), where most of the people live in highlands 2,000 metres above sea level and practice subsistence farming. There are few all-weather roads in the area, although most of the population lives in the highlands without access to roads. Health care is provided by three hospitals, 63 health centres and by rural health extension workers in 483 kebeles, which are Ethiopia’s lowest administrative units, with an average coverage of 1,000 households (population of 5,000). Hospitals are expected to provide comprehensive emergency obstetric care, while the health centres are expected to provide basic emergency obstetric care. Due to limited access to hospitals, senior staff (health officers) are given minimal training, and provide services such as caesarean sections in some health centres. Four (6%) of the health institutions in the area are accessible by asphalt roads, 21 facilities (32%) are accessed by all-weather gravel roads, 30 health centres (46%) are only accessible by car during the dry season and 11 institutions (17%) could not be accessed by a vehicle at the time of the survey. Administrative map of Gamo Gofa Zone and its Woredas, south-western Ethiopia, 2010. We conducted this study as part of a public health intervention project aimed at reducing maternal mortality in Gamo Gofa. A few years prior to the study, the intervention programme (“Reducing Maternal Mortality in south-west Ethiopia”) had started training non-physician clinicians (NPCs) to provide EmOC, including caesarean sections. The programme aims to support public health services to help reduce maternal and neonatal deaths [10], and is primarily a support to government institutions with training, supervision and providing the institutions with basic equipment. Thus, while the population in 2007 had only one hospital capable of doing comprehensive EmOC for approximately 1.7 million people, the services such as caesarean section delivery had improved to three hospitals and two health centres (one institution per 350,000 people) by 2010. The project also includes studies on estimating maternal and neonatal mortality through community-based birth registries, estimations of maternal mortality through the sisterhood method, large-sample household survey to estimate maternal and neonatal deaths and a health facilities obstetric care quality study (the current study). We collected data using questionnaires and procedures developed according to UN guidelines [8], and assessed the performance of health institutions using the same guidelines. We recruited eight health officers (people with bachelor’s degrees in clinical and community medicine) to collect the data, and the health officers were trained for two days before visiting the institutions. If deemed necessary, key health personnel at each institution were interviewed for the clarification of any recorded data. Between September and November 2010, we visited 66 health institutions, the three hospitals in Arba Minch, Chencha and Sawla and 63 health centres throughout the Zone. When visiting the institutions, we retrospectively reviewed one year of available obstetric services, records, documents, cards and registration books related to delivery services. As a result, we collected information from records and registers such as admission registers, delivery registers, delivery log books, referral registers and death registers. We also registered the number of staff available for obstetric care at each of the health institutions we reviewed. As recommended by the WHO guidelines for areas with fewer than 100 facilities, we included all hospitals and health centres in Gamo Gofa in the current study [8]. We used SPSS (version 16; SPSS, Inc., Chicago, IL, USA) for data entry and statistical analysis, and we performed a descriptive analysis to present rates and ratios. We calculated the expected number of deliveries for each woreda using the Central Statistical Authority (CSA) estimates for birth rates (3.7%) and woreda population size [11]. An EmOC facility refers to whether or not an institution is fully functioning as a basic or comprehensive facility [8]. Functioning is defined by nine signal functions, as follows: administering parenteral antibiotics, administering parenteral oxytocic drugs, administering parenteral sedatives, manual removal of the placenta, removal of retained products of conception, vacuum-assisted vaginal deliveries or forceps deliveries, performing caesarean sections, performing newborn resuscitation and the availability of a blood transfusion service. An institution that had not performed any or only some of the signal functions during the past three months was defined as a non-functioning EmOC. The reasons for not performing signal functions may vary, and include a lack of equipment or medications or a lack of available skilled personnel. The data for this study was collected as a part of Meseret Girma’s master thesis at the University of Gondar, so ethical clearance was therefore obtained from the University of Gondar. After obtaining the clearance, we received written permission to carry out the study from the Gamo Gofa Zone Health Department and each of the woreda health authorities. Before starting to record information about the health institutions, we informed the leaders of each of the health institutions about the study. Lastly, we received a written consent from the head of each facility to allow us to conduct the study at the institution. The Regional Committee for Medical and Health Research Ethics of North Norway (REK Nord) also approved this study.