Reducing stillbirths in Ethiopia: Results of an intervention programme

Previous studies from South Ethiopia have shown that interventions that focus on intrapartum care substantially reduce maternal mortality and there is a need to operationalize health packages that could reduce stillbirths. The aim of this paper is to evaluate if a programme that aimed to improve maternal health, and mainly focusing on strengthening intrapartum care, also would reduce the number of stillbirths, and to estimate if there are other indicators that explains high stillbirth rates. Our study used a “continuum of care” approach and focussed on providing essential antenatal and obstetric services in communities through health extension workers, at antenatal and health facility services. In this follow up study, which includes the same 38.312 births registered by community health workers, shows that interventions focusing on improved intrapartum care can also reduce stillbirths (by 46%; from 14.5 to 7.8 per 1000 births). Other risk factors for stillbirths are mainly related to complications during delivery and illnesses during pregnancy. We show that focusing on Comprehensive Emergency Obstetric Care and antenatal services reduces stillbirths. However, the study also underlines that illnesses during pregnancy and complications during delivery still represent the main risk factors for stillbirths. This indicates that obstetric care need still to be strengthened, should include the continuum of care from home to the health facility, make care accessible to all, and reduce delays.

This research was 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. Birth and birth-outcome registration is part of the routine work of the HEWs in Ethiopia, which is acknowledged by the government. For the research part, the Institution Review Board for Health Research of Southern Nations Nationalities and Peoples’ Regional State in Ethiopia (SJ42/6677), and the Regional Committee for Health Research Ethics of North Norway (2011/2495/Rek nord), approved the study. Personal identifiers were removed from the stored data used for research. This study on decline of stillbirths is a follow up of an implementation study that aimed at improving maternal deaths [13]. This intervention study was done in the three same districts (woredas) in South-west Ethiopia in the Southern Nations, Nationalities and Peoples’ Region. The data collection on information such as recruitment, data collection, and data analysis are presented in an earlier study [13]. As written in our earlier papers, “this study involved people from different cultural backgrounds and three ethnic groups in south Ethiopia (Gamo, Zeisse, and Derashe). The study population comprises 38.312 deliveries in the Dirashe, Arba Minch Zuria and Bonke woredas (sub provinces). In 2010, about 170.000 people lived in Bonke. This woreda had no hospital providing CEmOC during the study; so, people in need of such services had to travel to the nearest hospital, the Arba Minch Hospital, found about 100 kilometres from Bonke. At the time of our study, roughly 380.000 people lived in the Arba Minch Zuria Woreda, and the district had one large hospital. In 2010, about 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 [15]. Our study involved people from different cultural backgrounds and ethnic groups. The area we conducted the studies in were similar in demographics, health services, road access, and economic structure with most rural communities in Ethiopia. To register births and stillbirths, we developed a birth registry using the existing community health workers, in which household visit is their routine activity, with priority given to households with pregnancies and births. The health extension workers who performed the birth registration and identified maternal deaths are distributed in the same proportion to the population and have the same training background, all are females and all have similar working conditions in the country” [13, 16]. Our implementation project worked closely with the health extension programme which represents a responsive health delivery system to people in rural areas and aims to ensure equitable access to disease prevention and control, family health service (including maternal and child health), hygiene and environmental sanitation, and health education [17]. The health extension workers (HEWs) are women, receive a one-year training, and are responsible for the health services for 500–1000 households. The HEWs who performed the birth registration and identified maternal and neonatal deaths, and stillbirths are distributed in proportion to the population size in the communities and have the same training background; all are females and all have similar working conditions in the country. Thus the HEWs can conduct a birth registration of high coverage and optimum quality, and can classify pregnancy and birth results in any rural community in Ethiopia [16]. With the Ministry of Health, we designed a project to strengthen the health care system [12, 13]. A particular emphasis was given to upgrading existing institutions so they could carry out antenatal care (ANC), 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. During the intervention period, the number of institution carrying our comprehensive obstetric emergency services, and neonatal intensive care units increased substantially. Details about the number and types of institutions before and after the interventions has previously been published [13]. WHO defines antenatal care (ANC) as “the care provided by skilled health-care professionals to pregnant women and adolescent girls in order to ensure the best health conditions for both mother and baby during pregnancy. The components of ANC include: risk identification; prevention and management of pregnancy-related or concurrent diseases; and health education and health promotion [18]”. In our study area, most of ANC was carried out by HEWs. Even if they are not defined as skilled health workers, they have a one-year training which includes basic ANC elements. The details of this work, including number of institutions and quality assessment of the work of the non-clinical physicians doing caesarean sections has previously been outlined [13]. The scope of the work, and the basic and essential equipment was defined as used for BEmOC and CEmOC services and outlined in WHO manuals [19, 20]. As outlined in details in our previous paper on reducing maternal deaths [13], “the mean number of antenatal visits for each woman was 2.6 (interquartile range (IQR) 2–4). However, this varied between the districts with an average of 3.0 (IQR 2–4) visits in Dirashe, 2.2 (IQR 1–3) visits in Bonke and 2.7 (IQR 2–4) visits in Arba Minch Zuria. Between 2010 and 2013, the percentage of pregnant women who attended four or more pregnancy controls improved by 28% in Dirashe by 16% in Arba Minch and by 17% in Bonke. Similarly, the number of women referred to an institution with a skilled birth attendant increased most in Dirashe, followed by Arba Minch, and least in Bonke.” The aim of the implementation 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 an institution is fully functioning as a BEmOC or CEmOC facility [21]. 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). Institutions, which in addition to these signal functions could do caesarean sections and have a blood transfusion service, were defined as CEmOC facilities. All institutions received basic equipment, and training in neonatal resuscitation. Each of the institutions were supervised, at least once every quarter, to monitor the progress of the work” [13]. In this implementation study, the primary outcome measure was stillbirths and we used the definition recommended by WHO as “a baby born with no signs of life at or after 28 weeks’ gestation” and measured as number of stillbirths per 1000 births [22]. The assessment of gestational age was based on a history of the last menstruation period. We also measured the use of antenatal controls, and other 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 or if the delivery was complicated. Illness during pregnancy and delivery was based on if the HEWs defined the pregnant or delivering mother to have had an illness. A complicated delivery was defined as a delivery that lasted too long, if the HEW or skilled birth attendant assessed the bleeding to be too heavy, or the mother was referred to an institution where the mode of delivery was not a normal cephalic delivery. Because the interventions we used are believed to be effective [23], we considered it unethical to introduce a control area without access to such interventions. Our study thus analyses trends in the use of interventions and simultaneously occurring reductions in stillbirths. Before starting the health interventions, we developed a community based birth registry. The aim of the registry was to monitor whether maternal mortality declined, if the mothers were referred or not, where the babies were delivered and who helped the mother during the delivery. Using the skills of the Health extension workers (HEWs), we set up, field-tested, validated, and implemented a community-based birth registry to record births and outcomes such as maternal deaths, neonatal deaths and stillbirths [13, 14]. This population-based birth registration system was validated comparing the community birth registration with cross-sectional surveys, the sisterhood method and with the institutional-based registration of maternal deaths [14, 16]. Our conclusion was that the birth registration done by health extension workers provides a valid, community-based measurement of maternal deaths [16]. However, even if the maternal mortality measurements were found to be valid using the birth registry, we found that the population coverage the birth registrations were about 72%, with women living furthest away having lower coverage in the birth registry [14, 16]. Although we did not validate to register stillbirths as we did for maternal and neonatal deaths, we retrospectively recorded 226 stillbirths over a five-year period (2007–2011) [14]. On the average, that is about 45 stillbirth deaths per year, and in agreement with the first assessment in 2010 in Bonke [24]. 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 (from 2010 to mid-2013) of quality assured, and uninterrupted data collection and 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, and we therefore only included data in which supervisory nurses checked the quality of the birth registration. Data were entered into a computer using SPSS software (SPSS Inc. Chicago, IL), and the data were later checked for completeness and errors, and the paper forms could be returned to the health post for further checks. For the analysis, we calculated yearly stillbirth incidence rates, and odds ratios (problem during delivery, illness during pregnancy, sex of baby, age of the mother, father education, availability of CEmOC services, use of 4 or more antenatal visits) and logistic regression for multivariable analysis. The results are presented with P values and crude and adjusted Odds ratios with 95% confidence intervals.

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