Ethiopia is one of the countries with a high burden of maternal mortality. Approximately 13,000 maternal deaths occur each year, which equates to 35 per day. Countdown to 2015 has estimated that Ethiopia’s MMR has dropped to 420 deaths per 100,000 live births from around 1400 in 1990. The Ethiopian government officially recognises an MMR figure of 676, taken from the 2011 Demographic and Health Survey, and remains committed to reaching its MDG 5 target of 267.
The National MDSR System
As part of its drive to tackle maternal mortality, the Federal Ministry of Health (FMOH) formally launched the national Maternal Death Surveillance and Response (MDSR) system in May 2013 with the first Training of Trainers workshop, with over 100 participants from the four most populous regions (Amhara, Oromiya, SNNPR, Tigray) and the cities of Addis Ababa, Harar and Dire Dawa.
Materials for the training curriculum and the national Technical Guidelines were prepared by the multi-stakeholder MDSR Task Force, which continues to be responsible for overseeing the MDSR system and spearheading its development.
The National MDSR Guidelines can be downloaded here.
Following the launch, MDSR has been introduced in over 30 zones through “cascade training” in which regional level maternal and child health team members are responsible for training zonal and woreda level public health officials as well as medical personnel from hospitals and health centres.
The training is delivered through practical exercises and problem-solving activities, providing trainees with opportunities to familiarise themselves with the new data collection instruments, and “hands on” experience in aggregating and reporting data, and interpreting it to assess what actions should be taken at each level.
The National MDSR curriculum and related materials can be downloaded here.
By the end of 2014, the MDSR system had been introduced in areas covering roughly 40 million people. To monitor MDSR roll-out and maximise its sustainability, indicators of MDSR functionality have been added to the supportive supervision checklists, ensuring that regional health bureaux staff assess progress in the system at zonal and woreda levels.
Similarly, zonal and woreda supervisors address challenges encountered further down the system, right through to the primary health care units, including health extension workers’ engagement with communities, where they raise awareness about the importance of notifying all deaths to women of reproductive age in order to maximise identification of maternal deaths.
More recently, maternal deaths have been integrated into the national Public Health Emergency Management (PHEM) programme, which is delivered through the Ethiopian Public Health Institute (EPHI). This means that surveillance officers all over the country will be responsible for ensuring timely and accurate reporting from HEW upwards, and will manage a national database for all maternal deaths for which a verbal autopsy has been completed.
The verbal autopsy tool records key information from family and community members who were present during a deceased woman’s illness and death. A short interview asks about her previous medical history and care, signs and symptoms experienced soon before death, and the process of decision-making and care-seeking.
The vast majority of maternal deaths in Ethiopia occur in homes or in transit, making it crucial to focus MDSR data collection at the community level. A separate process of notification, data extraction from medical notes and attending health providers, and review will occur in hospitals and other health facilities following a maternal death.
The figure below summarises the process of MDSR data collection and review, from initial identification of the death of a woman of reproductive age to addition of her case-based data into the national data management system:
E4A Contribution
Evidence for Action is a DFID-funded programme to improve maternal and newborn survival in six sub-Saharan African countries, including Ethiopia. Globally, the London based consultancy Options oversees E4A, but in Ethiopia, technical support is provided by the University of Aberdeen’s IMMPACT initiative under the leadership of Professor Wendy Graham. E4A is hosted by the WHO Ethiopia country office.
Ethiopia based staff include a Country Director, two International Technical Advisors, 6 regionally located Country Technical Advisors and 1 Data Manager based within the PHEM unit at EPHI.
Together, the E4A team has contributed to the design of the national MDSR system, helped develop the national guidelines and national training curriculum, and provides regular and intensive support for MDSR’s introduction, implementation and evaluation in 10 focal zones located across 6 regions / cities (Addis Ababa, Amhara, Dire Dawa, Harar, Oromiya, SNNPR, and Tigray) as well as for central data aggregation, management and analysis.
Experiences from the Field
The most important part of MDSR is the “R” – Response. Data collection and reporting will only help reduce maternal mortality if they are used to identify effective, evidence-based, practical actions that can be taken at each level of the the health system, and beyond it (such as improving the reliability of electricity supply to health centres).
Although Ethiopia’s MDSR system is still in its early phase, there are already signs that an increased focus on the preventable determinants of maternal deaths are leading to improvements in quality of care and health system functioning in both facilities and in the community.
Case study 1: Hospital Based Reviews Improve Quality of Care
A 22 year old woman in her first pregnancy was referred from a health centre to the district hospital. On arrival she was at full dilatation with obstructed labour and having abnormal body movements. She was delivered with forceps shortly after admission.
She collapsed very soon after delivery and was bleeding significantly despite a reasonably well contracted uterus . The conditions were difficult as there was a power failure and no functional generator.
The case was discussed at the hospital MDSR committee meeting and it was agreed that senior help should have been called. Furthermore, both an Electricity generator and a biochemistry machine were purchased by the hospital in response to this case.
Fourm weeks later there was a very similar case when a 27 year old woman delivered at home was admitted to the district hospital on day 1 post partum. On arrival she had abnormal body movements and was unconscious. All resuscitative measures were done and senior staff including calling the Emergency Surgical Officer, the Gynaecologist and Internist.
Thus lessons from the response in the first case had been learnt and remembered by the staff. This demonstrates how the cycle of data collection, review and interpretation can lead to improvements in quality of care.
Case study 2: Using Verbal Autopsy to Learn from Community Deaths
Midwives from a rural health centre were alerted by a HEW to a maternal death in a village 7km from their health centre. They followed the National Guidelines in MDSR and carried out the verbal autopsy.
The woman was a 35 year old who had experienced 6 deliveries; she had just delivered the most recent at home, unattended. Following delivery she haemorrhaged but the family had been unable to obtain help with transporting her and she died at home 6 hours after giving birth.
The village leader was present during the verbal autopsy and became aware of the need for women to use the local health centre to prevent avoidable deaths. He declared all pregnant women would use the health centre for delivery in the future.
The woman had attended once for antenatal care but her high parity had not been recognized as a risk factor. Awareness has been raised in this community about high risk factors for complications during delivery.
Future Activities
The E4A programme will continue through March 2016, and will focus on the following activities:
- streamlining the process of integrating maternal deaths into the PHEM surveillance system
- strengthening review committees at RHB and national levels to ensure useful interpretation of the data and translation of evidence into action
- assessing progress, including developing a monitoring and evaluation framework to track effectiveness of MDSR processes
- delivering refresher training to build up a pool of national and regional level trainers who can manage future cascade training in new areas where MDSR is introduced
Ultimately, for the national MDSR system to be sustainable, it needs to be fully absorbed into routine public health functions. Ideally, medical and public health personnel should be familiar with the procedures and requirements of MDSR prior to taking up their professional roles and responsibilities.
E4A is exploring how the MDSR training package can be combined with existing medical education for future doctors, nurses, midwives, public health officers and field epidemiologists.
For frontline Health Extension Workers, MDSR has already been added into both their initial training and the annual integrated refresher training curriculum.