Volume 81, Issue 1 p. 93-102
Averting maternal death and disability
Free Access

The FIGO Save the Mothers Initiative: the Ethiopia–Sweden collaboration

T. Mekbib

T. Mekbib

Population Council, Addis Ababa, Ethiopia

Search for more papers by this author
E. Kassaye

E. Kassaye

Department of Obstetrics and Gynecology, Yekatit 12 Hospital, Addis Ababa, Ethiopia

Search for more papers by this author
A. Getachew

A. Getachew

Ambo Hospital, Ambo, Ethiopia

Search for more papers by this author
T. Tadesse

T. Tadesse

Ambo Hospital, Ambo, Ethiopia

Search for more papers by this author
A. Debebe

A. Debebe

Ambo Hospital, Ambo, Ethiopia

Search for more papers by this author
First published: 28 March 2003
Citations: 26
Corresponding author. Tel.: +251-1-526574; fax: +251-1-526577

Abstract

The overall goal of the FIGO Save the Mothers Fund was to establish basic and comprehensive emergency obstetric care (EmOC) with the specific objectives of increasing the availability and utilization of quality obstetric care as measured by the UN indicators. As a result of this commitment by FIGO, the Ethiopian Society of Obstetricians and Gynecologists (ESOG) launched the Save the Mothers Project (SMP) in West Showa Zone (WSZ), Ethiopia in 1998 to implement and test a demonstration project and evaluate the feasibility and impact of the intervention. The overall objectives matched FIGO's—reducing maternal deaths by promoting the availability, access and utilization of EmOC services for women with complications of pregnancy and childbirth. The intervention package included capacity building as a major activity, and physicians and other service providers from Ambo Hospital, Shenen and Ijaji Health Centers were trained in EmOC. This was intended to combat the high staff turnover in the area. Equipment, materials and supplies were also provided to the demonstration sites to enable them provide basic and comprehensive EmOC services. The interventions, begun in 1999, led to improvements in availability, utilization and met need, which suggests that such an approach may eventually lead to the reduction of maternal deaths. The cesarean section rate for Ambo Hospital increased from 3.7% in 1998 to 17.3% in 2001—an almost six-fold increase. At Ambo Hospital both the total number of deliveries and cases admitted with obstetric complications have increased from baseline. Patients with obstructed labor comprise 39% of all obstetric patients making it the leading cause of hospitalization. Obstetric hemorrhage comes next with 24% of all admissions. The case fatality rate (CFR) (for direct maternal deaths) decreased from 7.2% at baseline, to 4.6% in 2001—showing a definite trend of improvement. Currently, there is 24-h EmOC service at Ambo Hospital where an obstetrician and general medical practitioners with EmOC training are responsible for the service. Shenen and Ijaji health Centers are upgraded in terms of training of staff members, provision of equipment and supplies, and regular supervision so that the community in these areas has access to basic EmOC services. To replicate similar activities, in a setting like ours, EmOC projects have to be low cost to attract decision-makers. The SMP used almost US $100 000 over 3 years to ensure availability of EmOC services for women in WSZ. A favorable political climate such as maintenance of relative peace, and flexibility in adapting to local conditions also contributed to the success of the SMP.

1 Introduction

Ethiopia is the second most populous country in sub-Saharan Africa with an estimated population of 65 million in 2001 [1], and an annual population growth rate of 2.9%. The crude birth rate is 40 per 1000 population and the crude death rate is 13 per 1000 [2]. The Demographic and Health Survey (DHS) conducted in 2000 [3] found a total fertility rate (TFR) down from 7.5 in 1990 to 5.9 in 2000—still very high. The DHS also showed an infant mortality rate of 97 per 1000 live births, a maternal mortality ratio of 871 per 100 000 live births, and a contraceptive prevalence rate of only 8%, which is one of the lowest in sub-Saharan Africa. The same report showed that the unmet need for family planning is 36%.

The maternal mortality ratio in Ethiopia remains higher than most sub-Saharan African countries. According to a recent WHO estimate, the maternal mortality for Ethiopia is 1800 per 100 000 live births [4]. A major cause of maternal deaths is complications from unsafe abortions [5–7]. The low availability of health services in Ethiopia limits access of the people to all health services including emergency obstetric care (EmOC) services.

Decades of work in many countries have led to the understanding that most life-threatening obstetric complications cannot be predicted or prevented, but they can be successfully treated if and only if prompt access to EmOC is ensured and skilled attendance is available [8]. To ensure accessibility, availability and utilization of emergency obstetric care services, and thereby create a demonstration model, the International Federation of Gynecology and Obstetrics (FIGO) supported by UNFPA, Pharmacia Corporation, and the World Bank launched the Save the Mothers Project (SMP) in five developing countries including Ethiopia. To show their commitment to safe motherhood, and discharge their social responsibilities, the Ethiopian Society of Obstetricians and Gynecologists (ESOG) and the Swedish Society of Obstetrics and Gynecology (SFOG) were twinned in a collaborative effort in the SMP.

The general objective of the SMP is to implement EmOC with a view to reducing maternal deaths in West Showa Zone (WSZ), Ethiopia by promoting the availability, access and utilization of EmOC services for women with complications of pregnancy and childbirth.

Specific objectives are to develop and implement a program model based on the ‘three delays’ model (i.e. delay in deciding to seek care, delay in reaching a facility and delay in actually receiving care at the facility) [9] for the reduction of deaths from pregnancy and childbirth; increase availability of EmOC services in WSZ through training, accurate record keeping, and by securing adequate staff; and by upgrading existing facilities through the provision of equipment, supplies and materials.

2 Methodology

We used the UNICEF/WHO/UNFPA Guidelines for Monitoring the Availability and Use of Obstetric Services [8] to monitor the implementation of the SMP in WSZ, rather than maternal mortality measures.

2.1 Operational definitions

Indicator 1. Availability of EmOC services: we focused on two levels of facilities: basic emergency obstetric care (BEmOC) and comprehensive emergency obstetric care (CEmOC) providing life-saving obstetric procedures including surgery. The UN Guidelines suggest minimum acceptable levels: there should be one facility providing CEmOC; and four facilities providing BEmOC for every 500 000 population. A BEmOC facility provides the following signal functions: administration of i.v. antibiotics, oxytocics and anticonvulsants; manual removal of placenta; completing incomplete abortions, and conducting assisted vaginal delivery. A CEmOC facility provides the following signal functions: all the above basic functions plus cesarean section and blood transfusion services.

Indicator 2. Proportion of all births in EmOC facilities: minimum acceptable level: at least 15% of all births in the population take place in an EmOC facility (both basic and comprehensive).

Indicator 3. Met need for EmOC: minimum acceptable level: the proportion of women with obstetric complications who are treated in EmOC facilities is 100%.

Indicator 4. Cesarean section as a proportion of all births. Minimum and maximum acceptable levels: cesarean sections should account for not less than 5% or more than 15% of all births in the population.

Indicator 5. Case fatality rates: maximum acceptable level: the case fatality rate among women with obstetric complications in EmOC facilities should not exceed 1%.

The main project area is Ambo town, the principal town of WSZ where the Zonal Hospital is located. Ambo has a population of 228 503 people, and is 130 km from Addis Ababa. Within WSZ, there are 23 Woredas (i.e. districts) with over 2.6 million people. When the needs assessment was conducted in June 1998, there were only four functional health centers in WSZ. Out of these, because of their accessibility and population size, only two health centers were chosen to be included in the project.

The health centers chosen were Shenen (in Nono district with a population of 119 713) and Ijaji (in Chelia district with a population of 221 840). Shenen Health Center is approximately 87 km from Ambo Hospital with a gravel road. Ijaji Health Center is 97 km from Ambo Hospital with an asphalted road. In addition, out of the 23 districts in WSZ, at least 13 of them (with a population of over 1.7 million people) use Ambo Hospital as a CEmOC facility.

2.2 Needs assessment

ESOG and SFOG team members conducted a review of the reproductive health situation in WSZ in 1998 as the initial stage of the SMP. The assessment included: a review of available literature including surveys by the Ministry of Health such as Safe Motherhood Needs Assessments of 1996 [10] and the Reproductive Health Needs Assessment of 1997 [11]. They served as main source of information particularly on availability, use, management and quality of reproductive health services including EmOC services. Visits to WSZ demonstration site to assess the capability of the facilities to offer EmOC services, interviews with key informants and identified stakeholders to gather additional information were also conducted.

2.3 National seminar

A national Seminar was organized to discuss and reach a consensus on the following issues: findings of the needs assessment, identification of data sources, definitions of certain obstetric complications, and reporting formats and record keeping.

2.4 Interventions undertaken

Management and coordination: to ensure proper implementation of the SMP, Regional and Hospital Committees were established. Members of the Regional Committee are the Oromia Regional Health Bureau Head (chairman), Heads of the Regional Family Health, Planning, Health Services and Pharmacy Departments as well as SMP Project Coordinators. Members of the Hospital Committee include Head of the Zonal Health Department (chairman), Medical Director, Head of the Zonal Women's Affairs Department, Administrator, ob/gyn specialist, pharmacist, and senior midwife as well as project coordinators. Duties and responsibilities of these committees were worked out, and regular meetings held.

Equipment, supplies and drugs: equipment, materials and supplies were provided to Ambo Hospital and Shenen and Ijaji Health Centers, starting from the date of the launching of the SMP and refurbishment of expendable materials are conducted when the need arises. Some of the materials and equipment provided were suction machines, vacuum extractors, oxygen cylinders of different sizes, cesarean section and laparotomy sets including MVA, plastic sheets for mattresses, plastic boots, surgical gloves. A special pharmacy was opened in Ambo Hospital to make available drugs for EmOC at a reasonable price. Life saving drugs at Ambo Hospital and the two health centers are provided free of charge.

Training of service providers: three rounds of training were conducted for general practitioners (GPs), midwives, and other service providers in EmOC. This training focused on life saving procedures in obstetric emergencies (cesarean sections, cesarean hysterectomies including management of incomplete abortion, post abortion care (PAC) and management of ectopic pregnancy). During this period, seven GPs, four midwives, five health officers, and 18 health assistants from Ambo Hospital and the two health centers were trained. A 3-month training period for GPs in a busy ob/gyn department of the Gandhi Memorial Hospital in Addis Ababa was found to be adequate. Two midwives were also trained in the same institution as master trainers in BEmOC. Teams from the health centers were trained in rotation in Ambo Hospital by the master trainers trained in Addis Ababa supported by one ESOG member also from Addis Ababa. A master trainer, a trained GP and an ob/gyn specialist assigned to Ambo Hospital, conducted subsequent training. A 1.5-month training period for these service providers in BEmOC was also found to be acceptable. The training program did not include the training of anesthesia nurses.

Record keeping: improvement in record keeping was observed not only in Ambo Hospital, but also in the two health centers after the first round of training. Midwives were assigned this responsibility in all facilities, and this activity is being strengthened by regular supervision. The SMP reporting formats (adopted from the UN Guidelines for Monitoring the Availability and Use of Obstetric Services) are filled and collected regularly by project coordinators and principal investigator to generate information about EmOC services in Ambo Hospital and the two health centers.

Blood supply: to ensure a regular supply of blood for transfusion in Ambo Hospital, ESOG made an agreement with the Ethiopian Red Cross Society (ERCS) at the beginning of the SMP. Every 2 weeks a car from Ambo Hospital goes to Addis Ababa to collect HIV screened blood. However, there remain problems of transportation and storage, and the inadequate supply of blood available from the ERCS Blood Bank continues.

Functionality of the new block: the people of Ambo built a new block for obstetric services. Before the launching of the SMP the new block stood for over 2 years without electricity and water supply. After securing a dependable supply of water and electricity, the intervention activities started by moving all the obstetric and gynecological services including the operation theater to the new block thereby creating a much better environment for both service providers and patients.

Community involvement: the community in Ambo was invited three times during the graduation ceremonies of trainees in EmOC and handover of equipment, materials and supplies to Ambo Hospital and the two health centers.

Community representatives obtained first hand information about the SMP, raised various questions and received answers. Their suggestions to improve EmOC services were also received positively by the health officials of the Zone and Region.

3 Results

3.1 Needs assessment

The needs assessment identified the limitations and constraints of EmOC services in WSZ. It was learned that obstetric indicators for WSZ were among the worst in the country. Specific issues identified during the needs assessment included:
  • Poor administration and lack of accountability.

  • Shortage or absence of trained manpower at all levels.

  • Non-conducive working environment (absence of incentives to staff, inadequate manpower, poor condition of walls and ceilings) in labor wards and operation theater where standard and emergency obstetric services are carried out.

  • Shortage of essential drugs and supplies (i.e. uterotonic agents, antihypertensive drugs, suturing materials, surgical gloves); lack of medical equipment (malfunctioning vacuum extractors, incomplete laparotomy, cesarean section and MVA sets).

  • No blood transfusion services.

  • No GPs or other health workers trained in EmOC to perform life-saving procedures.

  • No effective referral system between Ambo Hospital and the identified health centers.

  • Acute shortage of health facilities and service providers in the area.

  • Gaps in knowledge and skill among service providers.

  • The new block at Ambo Hospital was not yet functional.

  • No effort to involve the community.

Moreover, Ambo Hospital, being the only Zonal Hospital in the area, is expected to be a CEmOC facility. However, the EmOC service was not provided round the clock and it was below acceptable standards.

3.2 Access/coverage in EmOC services in WSZ

Availability: according to the UN, for every 500 000 population, there should be at least four basic and at least one CEmOC facilities. To meet this minimum requirement WSZ needs at least four more CEmOC hospitals and another 18 BEmOC health centers. The needs assessment identified this huge shortfall in the EmOC service coverage of the area.

Utilization: Table 1 shows utilization of EmOC services in WSZ by taking the crude birth rate (CBR) at 40/1000 population. The utilization of EmOC services in the area is very low —6.1% in 1999 (baseline) and 7.6% in 2001 (from the estimated total births and the actual births reported in EmOC facilities).

Table 1. Access to and coverage of emergency obstetric care (EmOC) services in West Showa Zone, Ethiopia (1999–2001)
Estimated need for EmOC 1999 2000 2001
Population 2 563 226 2 625 384 2 675 734
Estimated total birth per year 102 529 105 015 107 029
@ 40 per 1000 population
Estimated need for cesarean 5126 5251 5351
sections per year @5%
Estimated number of complications 15 379 15 752 16 054
per year @15%
Documented births per year 6236 6651 8163
in all EmOC facilities
Utilization (%) [documented 6.08 6.33 7.62
births/estimated births]

Met need: the met need in EmOC services in 2001 (Table 2) for WSZ was only 8.7%. This is calculated by estimating the needs for EmOC services (15% of all births), and comparing it with the number of births in EmOC facilities.

Table 2. Met need in emergency obstetric care services in West Showa Zone, Ethiopia, 2001
Indicator Estimated number Number of births in Actual rate Target rate
in need per year EmOC facilities (%) (%)
Utilization 197 029 8163 7.6 15
Met need 16 054 1399 8.7 100
(15% of total)
Cesarean   5351 171 <0.1 5–15
section rate
(5% of total)

Cesarean section rate: the population-based cesarean section rate was also very low (0.16%) even after the intervention.

3.3 Performance of Ambo Hospital

The hospital-based cesarean section rate for Ambo Hospital for the years 1998–2001 is shown in Fig. 1. The baseline cesarean section rate was 3.7% in 1998; it reached 17.3% in 2001—a more than a six-fold increase (Table 3). The cesarean section rate in Ambo Hospital is increasing because of a considerable increase in admission of complications requiring this surgery.

Details are in the caption following the image

Cesarean sections at Ambo Hospital (1998–2001).

Table 3. Obstetric patients in Ambo hospital, West Showa Zone, Ethiopia (1998–2001)
Cases 1998 1999 2000 2001
Total deliveries 709 692 856 991
Normal deliveries 614 565 572 638
Instrumental deliveries 40 56 132 163
Obstetric complications 128 250 320 432
Cesarean sections 27 54 117 171
(3.8%) (7.8%) (13.7%) (17.3%)

The performance of Ambo Hospital before the SMP intervention was very poor as seen by the number of cesarean sections, number of deliveries and obstetric complications treated. However, as soon as implementation of the SMP started, the total number of deliveries at Ambo Hospital increased by 39.7% from the baseline when compared with the year 2001 (Table 3). This trend is also true for cases admitted to Ambo Hospital with obstetric complications during the intervention period. Types of obstetric emergencies in Ambo Hospital are indicated in Table 4. Patients with obstructed labor comprise 39% of all complications making it the leading cause of hospitalization in the area (Fig. 2). Then comes hemorrhage with a 24% of admissions for obstetric complications. Cesarean hysterectomies and uterine repairs for ruptured uteri secondary to obstructed labor were included along with cesarean sections. Instrumental deliveries have increased from 6% in 1998 to 23% in 2001 suggesting that the training of service providers had an impact.

Table 4. Types of obstetric emergencies in Ambo Hospital, West Showa Zone, Ethiopia (1998–2001)
Indicators 1998 1999 2000 2001 Percent increase
2001 over 1998
Hemorrhage 43 63 69 92 114
Prolonged/obstructed labor 31 84 140 181 483
Postpartum sepsis 8 14 11 17 112
Abortion complications 29 35 39 45 55
Pre-eclampsia/eclampsia 5 30 21 37 640
Ectopic pregnancy 4 10 16 21 425
Ruptured uterus 8 14 24 39 387
Total 128 250 320 432 237
Details are in the caption following the image

Leading obstetric complications at Ambo Hospital (1998–2001).

The case fatality rate (CFR) is calculated dividing the number of direct maternal deaths by the number of women admitted with direct obstetric complications. Although still very high, the CFR (for 1999 it was 7.2% based on 18 deaths; and for 2001 was 4.6% based on 20 deaths), shows a definite trend of improvement.

3.4 Performance of the health centers

The total number of deliveries and obstetric complications at the two health centers, Ijaji and Shenen (not shown) shows a slow rate of utilization of the EmOC services. From 38 deliveries in 1999 for Shenen, and 206 for Ijaji for the same year, there were 76 and 362, respectively, for 2001.

Shenen had an average of three deliveries per month in 1999, but this figure reached six deliveries per month in 2001. Ijaji, from an average of 17 deliveries per month, reached 30 deliveries per month in 2001. In spite of the fact that the two districts have a population of over 340 000 people, the number of women using these facilities remains small.

District health officials report that many deliveries are conducted at home by traditional birth attendants (TBAs). Referrals from the two health centers to Ambo Hospital were not regular. Ijaji Health Center refers on average two to three cases in 3 months. Most of the diagnoses on referral are obstructed labor or ruptured uterus. Personnel accompany some of the referrals from Ijaji health Center, as they have a pick-up car. Shenen Health Center, however, refers rarely, an average of only one to two cases in 6 months. This needs to be studied further to increase the utilization rate and timely referral of patients who need CEmOC services.

3.5 Cost of the project

Of US$101 202 advanced from FIGO for project implementation between 1998 and 2001, almost $100 000 was used for major activities under the categories shown in Table 5. This amount does not include money disbursed from FIGO to the Swedish Society.

Table 5. Save the Mothers Project local expenses during the 3-year implementation period (1998–2001)
Category US Dollars
Medical equipment: 28 662
Expendable 2896
Non-expendable 25 766
Training: 48 175
Training & seminars 32 059
Travel & per diem 16 116
Administrative: 22 687
Personnel 4203
Other administrative costs 10 045
Local consultants 752
International experts 391
Reporting and printing 1867
Sundry 5429
Total 99 525

4 Discussion

WSZ does not meet minimum criteria for obstetric coverage set by the UN; the zone therefore needs an additional four hospitals and 18 health centers to be built to provide services for treating obstetric complications. Currently, a private NGO hospital is being built in the area with donor support, and it is expected to alleviate some of the maternal health problems. However, the SMP for the 3 years of its existence has brought about a moderate improvement in the availability and quality of EmOC services in the area.

The number of cesarean sections prior to the launching of the SMP was very low. Following the intervention, the number of cesarean sections increased by over six-fold, from 27 in 1998 to 171 in 2001. In other words, from an average of two cesarean sections per month in 1998, it reached almost 15 cesarean sections per month in 2001. Nevertheless, this is far below the UN's 5% target.

The utilization rate has shown a steady increase in Ambo Hospital and the two health centers (Ijaji and Shenen) from an average of 57, 17 and three deliveries per month in 1999 to 83, 30 and six per month in 2001, respectively. However, considering the total number of deliveries and complications in Shenen and Ijaji Health Centers, the utilization rate remains very low. The reason is attributed to the fact that many women deliver at home either with the help of traditional birth attendants (TBAs), relatives or neighbors. Therefore, community awareness activities along with focus group discussions (already under preparation) are expected to improve health-seeking behavior in these communities. Addressing the first and second delays in these communities is also expected to improve utilization of services for EmOC and thereby reduce maternal deaths.

Obstructed labor is the leading cause of admission to Ambo Hospital, and contributes over 39% of obstetric complications. As there is a serious problem of transportation, patients with obstructed labor come to Ambo Hospital 4 or 5 days after labor was started, often making their condition critical. Most arrive exhausted, anemic, and sometimes moribund state. Most obstetric complications needing operative intervention are managed successfully, and referrals to Addis Ababa have virtually stopped. Earlier, the main reasons for referral were a non-functioning operation room, absence of blood transfusion services and unavailability of personnel with the skills to do life saving procedures.

One of the reasons for identifying WSZ as a demonstration site was fistula (which is common in the area) and ruptured uterus secondary to obstructed labor. The SMP created an environment conducive to timely resolution of obstructed labor and ruptured uterus through BEmOC and CEmOC services, and this has moderately contributed in life-saving efforts and prevention of disabilities. Once again, the SMP shows that this approach is effective not only in saving lives, but also in preventing fistula formation and other maternal disabilities. Ensuring the availability of EmOC services is the first line of defense in the prevention of fistula, and the contribution of the SMP in this area is significant.

While the CFR at Ambo Hospital remains high, the trend is in a positive direction going from 7.2% for 1999 to 4.6% for 2001, approaching the target 1%. If patients present early to the demonstration sites instead of coming when obstetric conditions have worsened, then the number of deaths from obstetric complications will go down. The initiated work with the community to create awareness and manage distance and transportation problems is expected to have an impact in reducing unnecessary deaths.

Staff turnover has been and remains a major problem in the implementation of the SMP in WSZ. To combat this problem, a regular training of service providers was found to be effective, and needs to be complemented by administrative support from the Zonal Health Department and the Regional Health Bureau. The issue of motivation of service providers has not been resolved yet, but negotiations continue to find feasible mechanisms.

Twenty-four hour EmOC is now available at Ambo Hospital where an obstetrician and trained GPs and other service providers are responsible for the service. At the same time, Shenen and Ijaji health Centers are also upgraded in terms of training of staff members, provision of equipment and supplies, and regular supervision so that the community in these areas has access to BEmOC services. The availability of high quality EmOC in all the project sites is currently evidenced by an increase in the total number of institutional deliveries, cesarean section rates, and no referrals to Addis Ababa for obstetric reasons.

The SMP used almost $100 000 over 3 years (Table 5) to ensure availability and utilization of EmOC services for women in WSZ. Although $35 000 to $40 000 per year may appear relatively low cost, it is, nevertheless, the biggest deterrent to the replication of the SMP experience in other parts of Ethiopia.

During the intervention period, attention was given not only to providing medical equipment that was either not functioning or unavailable, but also to conducting training in EmOC for service providers, and providing regular supportive supervision. These activities consumed 77% of the available funds for project activities. Administrative costs including personnel and others comprised 23% of the expenditure.

Strengthening the existing reproductive health program of the Oromia Region in WSZ through the SMP model has made it possible to improve the availability of EmOC services in the area. This has brought about a sense of confidence and ownership to the people in WSZ. While only moderate, the achievements of the SMP generated much interest in Ethiopia, and other regions in the country would like to replicate the SMP model expecting ESOG to take the lead. The favorable political climate (such as maintenance of relative peace) and flexibility in adapting to local conditions have contributed to the successful implementation of the SMP.

Acknowledgements

The authors would like to acknowledge the staff of Ambo Hospital, Ijaji and Shenen Health centers and the Zonal Health Department. The all-round support provided by the Oromia Regional Health Bureau and the Family Health Department, Ministry of Health is greatly appreciated. Our sincere thanks also go to the Executive Committee of ESOG for their follow-up and guidance. The President and General Secretary of FIGO for their special interest and support are also acknowledged. Finally, a special word of appreciation also goes to Dr Barbara Kwast for helping us at the initial stage of the project.