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.