First Half-year report 2010 for RMM project

Deaths from maternal causes represent the leading cause of deaths among women of reproductive age in Ethiopia. Thus, in line with the Millennium Development Goal for maternal health (MDG-5), this health project aims to reduce maternal mortality among the target population by two-thirds by 2015.

Vision and aims of project
The vision of this joint collaboration with the Southern Nations, Nationalities and Peoples’ Regional State (SNNPRS) Health Bureau of Ethiopia (RHB) is to improve maternal health and make substantial decline in maternal mortality among the target population

The target population for this project are pregnant women in the following administrative areas of south-west Ethiopia: Gamu Gofa Zone, South Omo Zone, Basketo Special Woreda, Dirashe Special Woreda and Konso Special Woreda.

The Project collaborates with two levels of health institutions responsible for delivery services. Health extension workers are responsible for the kebele antenatal work, and hospitals and health centres are responsible for delivery services in the woredas and zones.

Experience from other countries show that two conditions are needed to reduce maternal deaths: Staff should be able to carry out comprehensive emergency obstetric care (CEOC), and these services should be available to and used by the pregnant women.

Work in 2010
It is encouraging that maternal mortality rates decline in Ethiopia [1]. I believe that this research may reflect the truth, and the increased coverage of essential obstetric services contributes to a decline in maternal mortality rates. In our catchment are, the number of Caesarean sections has doubled since its start in 2008, and has already averted many maternal deaths and deaths of newborn babies.

Training programme
A major problem in rural Ethiopia is the lack of trained health personnel. Our project represents the first attempt train non-clinician physicians on a larger scale. In May we presented the experiences from our work at a national workshop in Addis Ababa. We are encouraged by the new policy of the Ethiopian Government to upgrade 800 health centres to rural hospitals. Our project has enabled three hospitals (Gidole, Chencha and Saula) and two health centres (Kemba and Konso) to routinely provide their populations with CEOC. We currently work to enable the health centres in Basketo, Turmi, Melo and Kucha to routinely provide CEOC.

During the fist six months of 2010, we continued to train health officers, anaesthetic nurses and scrub nurses at Arba Minch Hospital and at Jinka Hospital. Staff from Basketo and Melo Health centres are being trained, and we expect these two health centres to start operations in September 2010.

The newly started training programme (for health officers, nurses, midwives and HEWs) at Jinka Hospital and in South Omo Zone is particularly encouraging. It also strengthens the work at the hospital, and makes the institution more sustainable. During 2010 Jinka Hospital will also start to train essential staff from Turmi Health centre.

It is encouraging to see that Jinka, Chencha, Saula, Gidole and Arba Minch hospitals and Kemba Health Centre routinely do comprehensive emergency obstetrics. Work also started work in Konso, but the work was unfortunately temporarily suspended because of administrative problems in the woreda. It now seems that these problems have been eased, and the work may start again.

We continuously review the operations done at the institutions, and the results are encouraging, and comparable to work done in Mozambique and Tanzania. The institutions are now also capable of doing the more difficult operations such as uterine ruptures. Each year we invite all workers taking part in the RMM project for a one-day workshop in Arba Minch to discuss progress and challenges. During these meetings we also discuss the performance at each institution.

The work of the RMM project has also resulted in the planning for two new hospitals in south Ethiopia. Budget from the government has been secured for a new hospital in Konso, and on August 1, the foundation stone of the new hospital in Kemba will be officially laid. The Kemba Hospital is funded by the Ethiopian Government.

Health extension workers (HEW)
The Training of HEW continues as planned. The training unit in Gidole is completed, and in July 2010, Midwife Demissew, who recently completed his BSc Midwife training, will take over the responsibility for the training programme.

During the last months many HEW have also been trained in south Omo. During this training, each HEW receives a pack of written teaching materials on normal delivery, risk assessment and antenatal care, and neonatal resuscitation. The evaluation of the HEW training is encouraging, but more hands-on training on deliveries is needed for each of the HEWs.

Equipment
All participating institutions have received basic equipment to carry our comprehensive emergency obstetric operations.

Supervision
One lesson from our work is the need to follow and support the health officers, anaesthesia nurses and midwives at the peripheral institutions. We thus supervise and support our collaborating institutions. We also encourage the institutions to collaborate with each other, and thus form networks that strengthen their work. For example, staff from Saula Hospital take part in our visits to Melo and Basketo. Arba Minch Hospital has developed very good working relations with the institutions in Kemba, Chencha, Gidole and Konso.

Building works
The building of the training centre in Gidole is now finished. We have also built or expanded Maternity Waiting Areas in Kemba and Chencha. Three new waiting areas are being constructed in Jinka, Saula and Gidole. The Jinka and Chencha buildings are to expand the capacity of the units.

The construction of a new women’s ward at Arba Minch Hospital is complete, and is now used by Arba Minch Hospital. Thus the hospital has new delivery ward, gynaecological department, outpatient department for women, a new fistula unit, and a new Mother and Child OPD. Two new operation theatres and a new sterilisation unit have also been completed. Although this construction is not a part of the RMM project, it strengthens the Arba Minch Hospital as a training and teaching hospital.

Operational research
As in many other African countries, Ethiopia lacks information on how many mothers die before, during or after delivery. Thus, by involving staff from regional health authorities, universities and health colleges, we have developed tools for community based birth registries. Health extension workers in each local community (kebele) register all births and delivery outcomes. With birth registries at institutions, this will provide the regional and national health authorities with essential information for planning and improving the health services. It will also enable the project to oversee if maternal deaths are reduced by two-thirds by 2015. Two Masters (Meseret Girma and Tadesse Data) and one PhD student (Yaliso Yaya) are now doing their research on institutional birth registries and on the kebele birth registries. We expect to have some results by the end of 2010.

Some opportunities and challenges
During the first two years of the project we have seen that when delivery services are provided near the patient’s home, women make use of the services. However, in some areas people seldom use available health services. During the first half of 2010, Elisa Riis and colleagues in South Omo have designed a Community Conversation programme on harmful traditional practices and reduction of maternal mortality. This pilot programme will be carried out in two kebeles in Male Woreda, and is done in close collaboration with Ethiopian Evangelical Church Mekane Yesus South-West Synod. Through this pilot project, we hope to learn and gain valuable experience that might be expanded to other areas.

The main risks to the sustainability of emergency obstetric care are skilled staff. Skilled staff tends to move to central places in the regions. As staff turnover is high, we need at least two to three staff at each institution, and the training programme must be continuous. On the positive note, most of the health officers and midwives are from the local area, and the government encourages the institutions to provide them with extra salaries. The good support from the Ministry of Health underlines the government’s committed to the Millennium Development Goals. And, all running costs at participating institutions are covered by the respective institutions through government subsidies and user fees.

Another challenge is related to the financial sustainability of health institutions. The new financial structure at hospitals health centres provides a good basis to secure day-to-day running of the institutions.


References
Hogan MC, Foreman KJ, Naghavi M, Ahn SY, Wang M, et al. (2010) Maternal mortality for 181 countries, 1980-2008: a systematic analysis of progress towards Millennium Development Goal 5. Lancet DOI:10.1016/S0140-6736(10)60518-1.