First Half-year report 2009 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.

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.

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.

Work in 2009
During the fist six months of 2009, four health officers, four anaesthetic nurses and four scrub nurses received training in Arba Minch Hospital. They now work at their home institutions. It is encouraging to see that four health officers at Chencha, Saula, Gidole and Arba Minch hospitals routinely do emergency obstetrics, including doing caesarean sections. The anaesthetic and scrub nurses all work in their home institutions.

A review of the operations they have done show the results are comparable to work done in Mozambique and Tanzania.

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. We therefore expect to learn important lessons from this work, that later can be expanded to other regions.

One lesson is that we need experienced staff to follow and support the health officers at the peripheral institutions. It is therefore encouraging that a health officer from Arba Minch Hospital, with 15 years of work experience from the operation theatre, joined our programme. We believe that he can play an important role in future supervision at the institutions, and thus secure an important part in making the programme sustainable. He now works at Arba Minch Hospital, and is also an assistant instructor for the new batch of health officers from Gidole, Kemba, Konso and Jinka that their training started in June.

Saula Hospital was opened in September 2008. After having been equipped by our project, and after we trained two staff to do operations, two anaesthetic and two scrub nurses, the population (500.000 people) in Gofa now have a hospital that routinely do caesarean sections. Similarly, the older Chencha Hospital now regularly performs emergency obstetric care.

Gidole Hospital is now a well-functioning institution that serves as our teaching model for other institutions. Emergency obstetric care is functioning, and many health extension workers receive practical training at the delivery ward. Our programme is that three health extension workers stay at the hospital for two weeks and get practical experience with deliveries. The training building construction is well under way, and we expect to start using it in the next months. In addition, midwives and nurses from Kemba, and Chencha have used the hospital for inn serve training.

In June we started to train health officers working at health centres. We expect that is will be more difficult to enable the health centres to do emergency obstetrics operations, than it was for the hospitals.

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) shall register all births and delivery outcomes. As well as 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 master students have now been registered at Gondar University, and one PhD student shall soon be registered at the University of Bergen. They shall do their research on institutional birth registries and on the kebele birth registries.

Some challenges
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.

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. However, each institution must find their ways to keep essential staff. Such processes are under way at the institutions in our project.

One of the long-term aims of our project is to make the training programme sustainable, so it will continuously be managed and run by the region. During the coming year, we shall discuss this with different levels of Ministry of Health and with Arba Minch University.

Activities in 2008

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.

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.

The project
The target population are pregnant women in two zones and three special woredas in south-west Ethiopia. About 2.5 million people live here. The regional government owns this project. It shall enable nine public health institutions to provide CEOC. In accordance with WHO recommendations, this will provide the target population with an acceptable coverage of CEOC.

The project aims to strengthen the antenatal services so the health extension workers can help normal deliveries and identify and refer women in need of help during delivery to health institutions. We shall enable these health institutions to practice safe delivery. As most maternal deaths occur with delivery, particular attention is on intrapartum care. Thus, we equip institutions, and train health officers, and midwifes, and operating theatre staff to get the necessary skills to carry out CEOC.

A pilot project in Ethiopia
A major problem in rural Ethiopia is the lack of trained health personnel. For 1991 to 2006, the number of doctors in public health institutions declined from 1658 to 638, and in 2006, there was one specialist in gynaecology and obstetrics per 1.8 million people. Because of this severe shortage of doctors in rural institutions, the government decided to train health officers to carry out Comprehensive EOC. Our project represents the first attempt to do this on a larger scale. We therefore expect to learn important lessons from this work, that later can be expanded to other regions.

Some results
I shall use the results in Gidole Hospital, as this well-functioning institution serves as our teaching model for other institutions. Although our project only started in 2008, we already see some encouraging results. Gidole Hospital, with a catchment area of about 200.000 people, was without doctors doing emergency obstetrics for long period during 2007 and 2008. In 2008, a health officer received training in emergency obstetrics, and midwives and nurses got in-service training. In addition, we evaluate all births in joint meetings, and we thus have routines to quality assure the delivery services.

Although the Gidole Hospital situation is still fragile, the hospital routinely uses partographs, gives parenteral antibiotics, oxytocic drugs and anticonvulsants for pre-eclampsia and eclampsia. Blood transfusion service is available and the staff routinely performs manual removal of placenta and retained products, they do assisted vaginal delivery and perform caesarean section. The caesarean section was during the last months done by a health officer on 11% of deliveries, and with good results. Between 25 and 40 pregnant women are at any time admitted to the maternal waiting area at the hospital. Over 80% of the operative emergency obstetric care is done on women staying in the maternity village. This shows the good work by the antenatal screening in the communities. Although institutional based deliveries are still lower than recommended, the number of deliveries in the hospital has doubled.

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

Training and supervision
Previous experiences in reducing maternal deaths partly failed because of lack of supervision. Not only should the institutions be able to carry out the tasks, but they must be able to carry it out on continuous basis and in sufficient numbers. It is essential with in-service training and monitoring of the quality of obstetric services. We also train experienced health staff to do the supervision, and provide practical support the new institutions, and thus secure the institutions mange the complex tasks of running an operating theatre.

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) shall register all births and delivery outcomes. As well as 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.