Work plans 2012-13

In August 2012 we started Phase II of the RMM work. The aim of the RMM programme is to reduce maternal and neonatal deaths in Segen Zone, Gamo Gofa Zone and in Basketto Special woreda.

During the first phase (2008 – 2011), we focussed on setting up institutions doing Comprehensive Emergency Obstetric care (CEmOC). While Arba Minch Hospital served as the main centre for training, Gidole, Saula and Chencha hospitals, and Konso, Kemba, Basketto and Melo Health Centres started to do caesarean sections through support by our project.

All these institutions are regularly doing caesarean. The challenge is the large populations living in the Gamo and in the Gofa highlands, in the remote Konso areas and in Aliy still have limited access to such services. This is the main challenge of the RMM Phase II project.

During the second phase (2012 – 2016) we aim to increase the coverage of Basic (BEmOC) and Comprehensive Emergency Obstetric Care (CemOC). We will set up five new CEmOC places in Kolme, Gawada, Gezzeso, and Beto and in Selam Berr (Kucha). We shall also do some work to improve the access by enabling other health centres to do BEmOC, and link the work at these health centres both to health posts in the kebeles, and to improve referrals to institutions doing CEmOC.

For this work we have now one Ethiopian coordinator in each of the zones. The coordinators shall manage the daily work, and visit and support the hospitals and health centres.

Arba Minch Hospital

Training Unit: The hospital works well as a training site for our project. Currently staffs from Kolme, Saula, Kucha and Chencha are being trained.

Blood Bank: The hospital has a well-functioning blood bank. This blood bank will serve as a training site for the hospitals in Gidole, Saula and Jinka.

Neonatal Intensive Care Unit: The hospital has recently opened such a unit. Three nurses have been trained in Addis Ababa, and three more nurses will go to Addis soon for training. The RMM project supports this unit with some equipment, in 2013; the unit will train similar staff from Gidole and Saula Hospitals.

Arba Minch University and Master programme in Integrated Emergency Surgery
Our aim is to support the Master programme in Integrated Emergency Surgery (Obstetrics, gynaecology and general surgery). There have been some delays in the start of the three-year course. Arba Minch University has now told us that they expect this training to start in two-months.

Improving quality of midwife training
We have started work to improve training students at the Midwife school at the Health Science College in Arba Minch. Particular attention is on enabling the students to aquire the necessary skills to do their work at remote health institutions.

Saula Hospital
The hospital works well. The number of deliveries has increased from about 50 four years ago, to 498 during the last year. They did about 140 CS. This is a great improvement, and shows that focused supervision and support can improve essential delivery services.

Blood Bank: The hospital has set aside two rooms to set up a blood bank. We shall order equipment and laboratory instruments, train staff, and we plan to start the blood bank in early 2013.

Neonatal Intensive Care Unit: The hospital has recently opened such a unit. In 2013, the unit will train similar staff from Gidole and Saula Hospitals.

Training at Saula Hospital: Saula Hospital has this month managed to employ a gynaecologist with experience in training health officers for emergency obstetrics. This is a great opportunity to strengthen the capacity at the hospital, and for the Gofa area (population almost one million). We will therefore start to train two health officers in emergency obstetrics in Saula.

Gidole Hospital
Gidole Hospital works well. A health officer who completed the masters in emergency obstetrics and surgery now also staffs the hospital. He was the first health officer who started operations in Gidole in 2008. He does emergency obstetrics, and some basic surgery, and the work is good.

Blood Bank: Gidole Hospital has rooms for a blood bank. They also have laboratory technicians that will receive training in Arba Minch. This work is scheduled for 2013.

Neonatal Unit: This unit shall train HEW and staff from health centres to do neonatal resuscitations. The hospital has set aside a room for this purpose. We have bought some equipment for this purpose.

Training Centre: The health centre needs some teaching materials. We have bought some training models from the Laerdal Foundation, and we shall buy some more equipment in the coming month.

Training of staff at Gidole Hospital: We shall also start to train nurses from health centres and health extension workers in Gidole (see community work). This is to give them practical training and aquire skills.

Chencha Hospital
This hospital continues to do CS regularly. Unfortunately, the work has not increased during the last years. Chencha hospital serves a large catchment population (about 400.000 people). These are concerns we shall address in the coming year.

Konso Health Centre
Konso Health Centre works well. From a problematic start in 2010, it has increased the number of yearly deliveries from about 100 to 480 last year (Ethiopian calendar 2004). Last year they did 42 caesarean Sections, without major complications. They referred some patients with severe anaemia and with uterus ruptures to Arba Minch Hospital. The health officers Tamiru and Etenesh are doing very good work, and they are eager to help expanding this work to other areas in Konso woreda. Tamiru has agreed to take part in supervising Arfaide HC.

The government plans to finish the new hospital in Konso in August 2013. They will then move the delivery services to the new delivery and operations wards. The RRM project plans to build a maternity waiting area at the new hospital, and we hope this will be ready to begin the new hospital. RMM will provide the new hospital with some more equipment, and we plan to start a blood bank.

Kolme Health Centre
The Kolme Health Centre has now been opened. As outlined in our plan, we started training a health officer to emergency surgery, a nurse for short-term training in anaesthesia, and a scrub nurse. We shall now buy the necessary equipment, and hope to start operation in early 2013.

Gawada Health Centre
This new health centre is now almost complete, and work will start in 2013. Meanwhile, we will support the start of the new delivery services at this HC.

Kemba, Basketto and Melo Health Centres
We started work at these health centres during the first phase of RMM. They function well, and Melo HC, the institution furthest away, is doing a good job. In two years they have done over 70 Caesarean Sections, and the number of deliveries is steadily increasing. Their good performance is of such a good quality that it merits consideration to expand the work and include a remote health centre and thus improve the referrals We will consider starting this in 2013.

Selam Berr (Kucha) Health Centre
We started planning for this work in 2011. Unfortunately, the building work was delayed, and this delayed the start. We have now started to train staff from the health centre, and hope to start operation in early 2013. A new hospital is being built near to the health centre, and the delivery services at the health centre will move to new buildings when the hospital starts in about one year.

Beto Health Centre
Beto is located about 80 km south of Saula, and near to the mountains north of Jinka. The catchment population are about 150.000 people, and include people from Beto woreda, the southern part of Zala woreda and six kebeles of Maale woreda in the South Omo Zone.

There is a clear need to improve the delivery services in this remote area. The woreda is supportive, and the health centre has a building with four rooms suitable for such a unit. The health centre has 24-hour electricity, good water supply, and a standby generator. The head of the health centre is a health officer, with many years of working experience from the operation theatre at Arba Minch Hospital.

Beto is in our 2013 plans, and we shall now start to train one health officer, one anaesthetist nurse, and one scrub nurse. We shall also buy equipment, and we hope to start operations in early 2013.

Gezzeso Health Centre
Our birth registration suggests the maternal mortality rate is high in the Gamo Highlands. The main reason for this is thought to be that this mountainous areas, with mountains above 4000 m has a high population density, and inaccessible by road. Gezzeso HC is located at the heart of this area. The HC has good water supply, a good building, a generator and solar electric supply, and enough staff. The catchment population is about 150.000 people, and include people from Bonke Kemba, Dita, and Arba Minch Zuria woredas. Gezzeso is in our 2014 plan, but we will try to include the start of this much needed work in 2013, and training of staff will start in March 2013.

Use of Birth registries
I have analysed the birth registries so far, altogether about 26000 births during the last three years. Unfortunately, some births in the last six months have not yet been entered our database, especially from Bonke and Gidole. With these limits, I believe that our data suggest some interesting findings:

The maternal mortality has decreased during the last three years. The trend is significant, but varies between the woredas.

The decline in MMR seems to be associated with the availability of delivery services in the woreda (coverage and accessibility). This is agrees with our earlier study on the performance of health centres and hospitals. The largest decline is in Gidole and in Demba Gofa (Saula). These are also the two woredas with the highest CS rates per population.

Community programme
Our aim is to reduce maternal and neonatal deaths, and stillbirths. Thus we need to increase and strengthen institutional delivery services, and improve referrals to the hospital. We aim to strengthen the delivery services and referrals at about 20 kebeles in Dirashe and Aliy woredas and at five health centres. We shall start with the Gato HC.

Gato Health Centre and five health posts: Gato Health Centre has a population of about 31000 people. There are four kebeles (Gato, Shillale, Ataya and Kolla Mashille) that refer patients to this health centre. The number of deliveries at this HC has increased much during the last year. They have now agreed to use all designated delivery rooms. The RMM Segen project has received an invitation from the Dirashe woreda to facilitate talks between health extension workers and traditional birth attendants. We would be happy to facilitate such talks, and see this as a possibility to strengthen institutional deliveries. We have also bought a motorcycle ambulance (see www.e-ranger.com) for Gato health centre. From this work we hope to learn more on how we can expand this work to the other health centres and health posts in the woreda.

Arfaide Health centre: This HC has a catchment population of 34000 people. Six kebeles (Lehaite, Tishmale, Galabo, Kemale, Gunjera and Osho) refer patients to this HC. The HC has one midwife, and several nurses that have received BEmOC training. They lack some practical training, and the HC lacks some essential equipment. We have agreed that the HC shall clear the necessary rooms for this work. We have also bought a motorcycle ambulance for Arfaide health centre.

Community programme at Loote HC: Loote Health Centre in Demba Gofa woreda near to Saula has a catchment population of about 34000 people. There are nine kebeles that refer patients to this health centre. The number of deliveries at this HC is about 5-8 each month. The infrastructure is good, but the HC needs some extra equipment and supervision. We have bought a motorcycle ambulance (see www.e-ranger.com) for Loote health centre. The distance to Saula Hospital is 18 km, and the road is good gravel road. We shall evaluate the work after some months, and evaluate if we can expand it to include health posts in the area.



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.

2009 report “Reducing Maternal Mortality”

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, and these services should be available to and used by the pregnant women.

Vision and aims of project
In this public programme, we work with the Southern Nations, Nationalities and Peoples’ Regional State (SNNPRS) Health Bureau of Ethiopia (RHB) to improve maternal health and reduce maternal and neonatal deaths 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 works 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.

Our work has four components:
  1. Train non-clinician physicians (health officers) and midwives to carry out comprehensive emergency obstetric care
  2. Equip institutions to carry out comprehensive obstetric services
  3. Make delivery services available through health extension workers to all local communities and thus to pregnant women among a population of 2.6 million people.
  4. Using a simple, cost-effective, and sustainable tool to monitor maternal and newborn deaths. These community-based birth and death registries use health extension workers to register all births and deaths that occur in rural communities

Work in 2009
During 2009, 10 health officers, 10 anaesthetic nurses and 10 scrub nurses received training in Arba Minch Hospital. They now work at their home institutions. It is encouraging to see the these teams of health staff at Kemba and Konso Health centres, and Chencha, Saula, Gidole and Arba Minch hospitals routinely do emergency obstetrics, including caesarean sections. In November another four health officers and anaesthesia nurses started their training. In addition, we have trained about 150 HEWs and 30 midwives and clinical nurses.

Our project represents the first try In Ethiopia to train non-clinician physicians on a larger scale, and we are encouraged to see that comprehensive obstetric care is done at health centres in Konso and Kemba. In 2009, the number of caesarean sections increased by almost fifty per cent among our target populations, and the number of institutions routinely doing emergency obstetric care increased from two to seven.

Monitoring of work
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. In 2009 we carried out pilot studies, and validated the tools to register births and deaths. In December we started birth and death registration for the population in Dirashe Special Woreda. This registration will enable the project to oversee if maternal deaths are reduced by two-thirds by 2015. Two master students now study at Gondar University, and one PhD student shall soon start at the University of Bergen.

We use experienced staff to follow and support the health officers at the rural institutions. In addition we continuously review the quality of the work at all institutions. So far, the results are encouraging and are comparable similar work started in other African countries.

Priorities for 2010
In 2010 we shall continue to strengthen the institutions, and through our Quality assurance, we systematic monitor and evaluate the work to ensure that standards of quality are being met. In 2010, our main emphasis shall be to strengthen the capacity of health extension workers, health posts and smaller health centres. The goal is to improve institutional birth coverage and that pregnant women in need of institutional care are referred in time.


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.