RMM Programme: Some remaining challenges
02/10/11
There has been a substantially improvement in the number of institutions providing comprehensive emergency obstetric care (from about 1 per 1.200.000 population in 2008 to 1 per 250.000 population at the end of 2010; see following table). Although this is an essential requirement to cut maternal and neonatal deaths, the use of such services remains below what is needed to reduce maternal and neonatal deaths. However, lack of ambulance services remains a great challenge.
It is also important, as asked by the zonal health authorities, to increase the number of institutions carrying our CEOC with 6. At the end of 2015, the area will then have one institution per 160.000 people. This is about the target the Ethiopian Government has set during the next five years.
Our study shows that of the 64 major health institutions in Gamu Gofa Zone, only a few were carrying out Basic Emergency Obstetric care. We therefore think it is essential to include these institutions in our future programme, and thereby improving the access of the population to such services, and to improve referrals to institutions with CEOC.
Although staff retention has been good, it is important to sustain staffing the institutions. Of particular importance is to improve the skills so more operations can be done at these remote institutions. We therefore aim to support a masters programme for health officers at Arba Minch University.
The main causes of maternal deaths, as documented by our review of health institutions and by our population-based registries, show that bleedings, infections and pre-eclampsia represent the main cases of death. As most of the births still occur at home and attended by traditional birth attendants or family members, we need to find ways to reduce bleedings and infections during home deliveries.
Several of the institutions carrying out CEOC do not functioning optimally because they lack adequate blood transfusion services. To reduce maternal deaths from bleeding and from uterine ruptures we need to improve the blood transfusion services at these institutions.
It is also important, as asked by the zonal health authorities, to increase the number of institutions carrying our CEOC with 6. At the end of 2015, the area will then have one institution per 160.000 people. This is about the target the Ethiopian Government has set during the next five years.
Our study shows that of the 64 major health institutions in Gamu Gofa Zone, only a few were carrying out Basic Emergency Obstetric care. We therefore think it is essential to include these institutions in our future programme, and thereby improving the access of the population to such services, and to improve referrals to institutions with CEOC.
Although staff retention has been good, it is important to sustain staffing the institutions. Of particular importance is to improve the skills so more operations can be done at these remote institutions. We therefore aim to support a masters programme for health officers at Arba Minch University.
The main causes of maternal deaths, as documented by our review of health institutions and by our population-based registries, show that bleedings, infections and pre-eclampsia represent the main cases of death. As most of the births still occur at home and attended by traditional birth attendants or family members, we need to find ways to reduce bleedings and infections during home deliveries.
Several of the institutions carrying out CEOC do not functioning optimally because they lack adequate blood transfusion services. To reduce maternal deaths from bleeding and from uterine ruptures we need to improve the blood transfusion services at these institutions.
Lessons learnt from Phase I of the RMM project
29/09/11
From our experience, it is encouraging that maternal mortality rates decline in Ethiopia. This may reflect an increased coverage of essential obstetric services that 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.
However, preliminary results from the birth registration from Dirashe, Bonke and Arba Minch Zuria shows the Maternal Mortality Ratio (MMR) might be as high as 545 per 100.000 births. Since we started the RMM project, stillbirths have recently received increasing attention, and these figures compare well with our birth registry reports, which show the stillbirth rate is about 50% of the neonatal mortality rate. This is the first result of such registration in Ethiopia, and provides the project with a unique opportunity to develop and monitor progress in reducing maternal deaths.
The RMM First Phase (2008 – 2011) highlighted the following strategy:
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. 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 four health centres (Kemba, Konso, Basketto and Melo) to routinely provide their populations with CEOC. We currently work to enable the health centres in Turmi, and Kucha to routinely provide CEOC. We continuously review the operations done at the institutions, and the results are encouraging, and comparable to work done in Mozambique and Tanzania.
The work of the RMM project has also resulted in the planning for two new hospitals in south Ethiopia: in Kemba and in Konso. We recently donated hospital beds and some medical equipment to the new hospital in Kemba.
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 up and support the health officers, anaesthesia nurses and midwives at the peripheral institutions. Thus, we supervise and support our collaborating institutions. We also encourage the institutions to collaborate with one another, and thus form networks that strengthen their work. For example, staff from Saula Hospital take part in our visits to Melo and Basketto. Arba Minch Hospital has developed good working relations with the institutions in Kemba, Chencha, Gidole and Konso.
Health extension workers (HEW)
Training HEW continues as planned. The training unit in Gidole is completed, and all HEW completed their training at Gidole Hospital Similar training has been done at Jinka, Arba Minch, Chencha and Saula Hospitals.
Building works
We built a training centre in Gidole, and we expanded or built Maternity Waiting Areas in Kemba, Chencha, Jinka and in Saula.
The new women’s ward at Arba Minch Hospital is complete. Thus the hospital has new delivery ward, gynaecological department, outpatient department for women, a new fistula unit, and a new Mother and Child OPD. The hospital has 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 why and 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.
Most encouraging: there has been a substantially improvement in the number of institutions providing comprehensive emergency obstetric care, from 1 per 1.000.000 population in 2008 to 1 per 250.000 population at the end of 2010. This is an essential requirement to reduce maternal and neonatal deaths.
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) completed their training in 2011, and one PhD student (Yaliso Yaya) continues his research on community based institutional birth registries.
Our preliminary results from the birth registration from the three woredas in Dirashe, Bonke and Arba Minch Zuria shows the Maternal Mortality ratio might be as high as 550 per 100.000 births. The mortality rates are lower for communities with better access to health institutions doing Comprehensive Emergency Obstetric Care. In remote areas, the maternal mortality rate is still very high (over 1500 / 100.000 births). More that 60% of the deaths are due to intrapartum bleeding. We therefore need to find methods to reduce bleeding after delivery when the birth takes place at homes.
The research done by Meseret Girma from Arba Minch University on 64 health centres and hospitals in Gamu Gofa Zone (population 1,7 million people) show that only 6% of the births takes place at health centres. More worrying, only 10 - 15% of deliveries with expected complications take place at health centres or hospitals.
However, preliminary results from the birth registration from Dirashe, Bonke and Arba Minch Zuria shows the Maternal Mortality Ratio (MMR) might be as high as 545 per 100.000 births. Since we started the RMM project, stillbirths have recently received increasing attention, and these figures compare well with our birth registry reports, which show the stillbirth rate is about 50% of the neonatal mortality rate. This is the first result of such registration in Ethiopia, and provides the project with a unique opportunity to develop and monitor progress in reducing maternal deaths.
The RMM First Phase (2008 – 2011) highlighted the following strategy:
- Improve coverage of institutions with Comprehensive Emergency Obstetric Care (CEOC, that is institutions doing caesarean sections)
- Train essential staff. We focused on training health officers, nurse anaesthetists, scrub nurses and midwives
- Equip the participating institutions with essential equipment to carry out CEOC
- Supervise staff at the participating institutions doing CEOC
- Improving the works of health extension workers so they refer delivery cases to institutions.
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. 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 four health centres (Kemba, Konso, Basketto and Melo) to routinely provide their populations with CEOC. We currently work to enable the health centres in Turmi, and Kucha to routinely provide CEOC. We continuously review the operations done at the institutions, and the results are encouraging, and comparable to work done in Mozambique and Tanzania.
The work of the RMM project has also resulted in the planning for two new hospitals in south Ethiopia: in Kemba and in Konso. We recently donated hospital beds and some medical equipment to the new hospital in Kemba.
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 up and support the health officers, anaesthesia nurses and midwives at the peripheral institutions. Thus, we supervise and support our collaborating institutions. We also encourage the institutions to collaborate with one another, and thus form networks that strengthen their work. For example, staff from Saula Hospital take part in our visits to Melo and Basketto. Arba Minch Hospital has developed good working relations with the institutions in Kemba, Chencha, Gidole and Konso.
Health extension workers (HEW)
Training HEW continues as planned. The training unit in Gidole is completed, and all HEW completed their training at Gidole Hospital Similar training has been done at Jinka, Arba Minch, Chencha and Saula Hospitals.
Building works
We built a training centre in Gidole, and we expanded or built Maternity Waiting Areas in Kemba, Chencha, Jinka and in Saula.
The new women’s ward at Arba Minch Hospital is complete. Thus the hospital has new delivery ward, gynaecological department, outpatient department for women, a new fistula unit, and a new Mother and Child OPD. The hospital has 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 why and 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.
Most encouraging: there has been a substantially improvement in the number of institutions providing comprehensive emergency obstetric care, from 1 per 1.000.000 population in 2008 to 1 per 250.000 population at the end of 2010. This is an essential requirement to reduce maternal and neonatal deaths.
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) completed their training in 2011, and one PhD student (Yaliso Yaya) continues his research on community based institutional birth registries.
Our preliminary results from the birth registration from the three woredas in Dirashe, Bonke and Arba Minch Zuria shows the Maternal Mortality ratio might be as high as 550 per 100.000 births. The mortality rates are lower for communities with better access to health institutions doing Comprehensive Emergency Obstetric Care. In remote areas, the maternal mortality rate is still very high (over 1500 / 100.000 births). More that 60% of the deaths are due to intrapartum bleeding. We therefore need to find methods to reduce bleeding after delivery when the birth takes place at homes.
The research done by Meseret Girma from Arba Minch University on 64 health centres and hospitals in Gamu Gofa Zone (population 1,7 million people) show that only 6% of the births takes place at health centres. More worrying, only 10 - 15% of deliveries with expected complications take place at health centres or hospitals.
First Half-year report 2010 for RMM project
29/07/10
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.
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”
01/01/10
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:
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.
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:
- Train non-clinician physicians (health officers) and midwives to carry out comprehensive emergency obstetric care
- Equip institutions to carry out comprehensive obstetric services
- 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.
- 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
12/09/09
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.
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.
