International Journal of Gynecology and Obstetrics

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1 International Journal of Gynecology and Obstetrics 115 (2011) Contents lists available at ScienceDirect International Journal of Gynecology and Obstetrics journal homepage: AVERTING MATERNAL DEATH AND DISABILITY Indicators for availability, utilization, and quality of emergency obstetric care in Ethiopia, 2008 Keseteberhan Admasu a, Abonesh Haile-Mariam b, Patricia Bailey c, a Federal Ministry of Health, Addis Ababa, Ethiopia b United Nations Children's Fund (UNICEF), Addis Ababa, Ethiopia c Family Health International (FHI) 360, Durham, USA article info abstract Keywords: Emergency neonatal care Emergency obstetric care Ethiopia Objective: To report on the availability and quality of emergency obstetric and newborn care (EmONC) in Ethiopia. Methods: All licensed hospitals and health centers were visited and standard questionnaires were administered. In addition, a nonrandom systematic sample was taken of recent cesarean deliveries, partographs, and maternal deaths and these cases were systematically reviewed. Health facilities were geocoded using geographic positioning system devices. Results: Too few facilities provided EmONC to meet the UN standards of 5 per population, both nationally and in all but 2 regions. Only 7% of deliveries took place in institutions of any type, and only 3% in facilities that routinely provided all the signal functions. Only 6% of women with obstetric complications were treated in any health facility, half of whom were treated in fully functional EmONC facilities. Nationwide, 0.6% of expected deliveries were by cesarean. The mortality rate for women with serious obstetric complications (case fatality rate) was 2%. The cause of death was unknown in 10% of cases, and 21% were due to indirect causes (primarily malaria, anemia, and HIV-related). Conclusion: None of the indicators met UN standards. Ethiopia faces many challenges not least geography with regard to improving EmONC. Nevertheless, the government places high priority on improvement and has taken (and will continue to take) action to achieve Millennium Development Goals 4 and 5. This comprehensive survey serves both as a road map for planning strategies for improvement and as a baseline for measuring the impact of interventions International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. 1. Introduction Maternal mortality is difficult and expensive to measure. Furthermore, knowing the level of maternal mortality does not contribute to understanding the factors that contribute to high or low levels of mortality. In recognition of these limitations, the UN agencies UNICEF, WHO, and UNFPA, together with the Averting Maternal Death and Disability (AMDD) program at Columbia University, New York, USA, developed the emergency obstetric care (EmOC) indicators for monitoring and evaluating the process and progress toward reducing maternal mortality [1]. These indicators (Table 1) depend largely on routinely collected data, and inform decision makers and program managers about the availability, utilization, and quality of emergency obstetric and newborn care (EmONC) Purpose In the present paper, we report on the status of the EmOC indicators in Ethiopia. The data were collected to help develop a national plan of Corresponding author at: FHI 360, 2224 E NC Hwy 54, Durham, NC 27712, USA. Tel.: ; fax: address: pbailey@fhi360.org (P. Bailey). action for achieving Millennium Development Goals (MDGs) 4 and 5, and to provide baseline data against which to measure improvements in availability and quality of EmONC as that national plan unfolds. The data collected are also being used to help strengthen the health system as a whole, using EmONC as a point of entry (the indicators are called EmOC indicators because their explicit attention to emergency neonatal care is limited to the signal function of neonatal resuscitation; however, EmONC better describes the scope of the assessment and the caring needed to improve both maternal and child outcomes). 2. Methods The methodology used to collect the indicator data was a crosssectional facility-based assessment of EmONC; it has been described in detail elsewhere [2] and we provide only a brief description here. The assessment was led by the Ethiopian Federal Ministry of Health (FMOH), with technical support from UNICEF, UNFPA, WHO, and AMDD. Funding was provided by the UN agencies. Beta Consulting Firm conducted the survey. Many similar needs assessments have been conducted (more than 70 at the time of writing), and several have been reported in this journal [3 7], yet this is the first published report of a census of all health centers and hospitals in the country and one that also used global information system /$ see front matter 2011 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. doi: /j.ijgo

2 102 K. Admasu et al. / International Journal of Gynecology and Obstetrics 115 (2011) Table 1 EmOC indicators. EmOC indicators Description Acceptable level Availability of EmOC: basic EmOC and comprehensive Ratio of to the population 5 per population 1 comprehensive facility per population Geographic distribution of Ratio of at subnational level As above Proportion of all births in Proportion of all births in the population in Recommended level to be set locally Met need for EmOC Proportion of women with major direct obstetric complications 100% treated in. The estimated number of women with direct obstetric complications is 15% of all expected births in the population Cesarean delivery as a proportion of all births Proportion of all births in the population by cesarean delivery 5% 15% in Direct obstetric case fatality rate Proportion of women with major direct obstetric complications b1% who die in Intrapartum and very early neonatal death rate Proportion of births that result in an intrapartum or a very To be determined early neonatal death (b24 hours) in Proportion of maternal deaths with indirect causes Percentage of all maternal deaths in with indirect causes None set Abbreviation: EmOC, emergency obstetric care. technology to map the location of those health facilities. It is also one of the first assessments to use the revised EmOC indicators released in June 2009 [1] Data collection instruments Questionnaire development was based on several modules of a standardized set of core modules that were pretested and adapted in Addis Ababa prior to the survey [8]. All questionnaires were in English and administered in English. One module focused on the signal functions of EmOC described in Monitoring Emergency Obstetric Care: a Handbook [1]; it was used to determine whether each signal function had been performed in the past 3 and 12 months, and the reasons why if it had not in the past 3 months. The second module was a summary of service statistics for the facility over 12 consecutive months. The items counted were vaginal and cesarean deliveries, direct and indirect obstetric complications, direct and indirect maternal deaths, and the number of stillbirths and very early neonatal deaths (b24 hours) Study population A census was taken of almost all health centers and hospitals in Ethiopia (some facilities in Somali region were excluded for logistic reasons). A small number were omitted because they did not appear on the list of licensed facilities that served as the master list. Although 806 facilities were visited, 9 (7 of which were hospitals) were dropped from analysis because they provided no maternity services and 2 were dropped because they were not forthcoming with crucial information; this left 795 facilities for analysis Analysis Standardized methods were used for the analysis of survey data (without correction for sampling). 3. Results Detailed results may be obtained from the project's final report [9] Availability of EmOC (indicator 1) Table 2 shows the number of, nationally and regionally. The majority (94%) of facilities were government managed. The term EmOC facility refers to a facility that is fully functioning as either a basic EmOC (BEmOC) facility or a comprehensive EmOC (CEmOC) facility. Functioning is defined by having performed the 9 signal functions (parenteral antibiotics; parenteral uterotonics; parenteral anticonvulsants; removal of retained products; manual removal of placenta; assisted vaginal delivery; and neonatal resuscitation for BEmOC; plus obstetric surgery and blood transfusion for CEmOC). The standard definition requires that the function had to have been provided during the past 3 months. Table 2 shows that, based on this definition, 58 facilities were fully functioning C (57 hospitals and 1 health center/clinic). Sixteen hospitals and 9 health centers were classified as B. Proportionally, private for-profit and notfor-profit facilities were more likely to function as BEmOC or CEmOC facilities than were government-run facilities. Monitoring Emergency Obstetric Care: a Handbook [1] recommends at least 5 per population, of which at least 1 provides comprehensive care. At 0.6 per population, Ethiopia falls far short of this goal. However, if all the existing facilities provided all the signal functions, the minimum-level goal would be achieved. Fig. 1 shows which signal functions were missing by level of facility. In some cases, the specifics of the function were not the preferred method: for example, ergometrine rather than oxytocin was used; diazepam rather than magnesium sulfate was used; or dilation and curettage rather than manual vacuum aspiration was used. Nevertheless, the function had been performed. Reasons for not providing a signal function included (in order of frequency): lack of supplies, equipment, or drugs; no patient presented Table 2 Availability of EmOC based on signal functions performed in the previous 3 months by type of facility and sector, Ethiopia a CEmOC BEmOC Partially functioning b Total No. Type of facility Hospital 57 (51.4) 16 (14.4) 38 (34.2) 111 Health center/clinic 1 (0.1) 9 (1.3) 674 (98.5) 684 Sector Government 45 (6.0) 22 (2.9) 682 (91.1) 749 Private for-profit 7 (26.9) 2 (7.7) 17 (65.4) 26 NGO, religious 6 (30.0) 1 (5.0) 13 (65.0) 20 Total 58 (7.3) 25 (3.1) 712 (89.6) 795 Abbreviations: BEmOC, basic emergency obstetric care; CEmOC, comprehensive emergency obstetric care; EmOC, emergency obstetric care; NGO, non-governmental organization. a Values are given as number (percentage) unless otherwise indicated. b Defined as a facility missing 1 9 signal functions.

3 K. Admasu et al. / International Journal of Gynecology and Obstetrics 115 (2011) conducted, there were an estimated 2.6 million births. Of these, 15% or nearly were expected to develop major obstetric complications requiring medical attention. Fig. 2 shows that, nationally, only 3% of these were treated in an EmOC facility and another 3% were treated in a partly functioning facility. The regions varied, from 0% in Somali to 49% in Harari, in any type of facility Cesarean delivery as a proportion of all births (indicator 5) Fig. 1. Percentage of hospitals and health centers performing the 9 signal functions, Ethiopia The UN recommends a range of cesarean deliveries between 5% and 15% of all births (not just institutional deliveries). The survey showed that the national average was 0.6% and only 2 regions had rates that fell within this range (Harari at 9.9% and Addis Ababa at 7.1%). with an indication for the function; lack of training; and other human resources issues Geographic distribution of EmOC (indicator 2) The recommended distribution of of 5 per population applies to regions as well as to the nation as a whole. In Ethiopia, facilities were concentrated in the center of the country, leaving peripheral areas underserved. Only 1 (Harari) of 11 regions met the goal of 5 per The most populous regions of Oromiya, Amhara, and Southern Nations, Nationalities, and Peoples (SNNP) had only 0.4, 0.4, and 0.5 EmOC facilities per , respectively. The city of Addis Ababa met the minimum recommended number of comprehensive facilities, but had no fully functioning B Proportion of all births that take place in facilities (indicator 3) The UN makes no recommendation on the proportion of deliveries that take place in facilities. Table 3 shows, for each region, that the percentage of expected births occurring in all facilities was only 7% (range, 2% 48% in the regions), and 3% in (range, 0% 40% in the regions) Met need for EmOC (indicator 4) The goal is to treat all women with serious obstetric complications in a fully functioning EmOC facility. In the year the survey was 3.6. Direct obstetric case fatality rate (indicator 6) The UN-targeted maximum case fatality rate is 1% of women with direct obstetric complications. Table 4 shows that the national case fatality rate for all direct obstetric complications was 2%: double the recommended maximum. Some regions were grouped because few maternal deaths were documented. The most common causes of direct obstetric death were (in order) obstructed labor, ruptured uterus, severe pre-eclampsia/eclampsia, postpartum hemorrhage (including retained placenta), and complications of abortion. The highest cause-specific case fatality rates were 6.4% for ruptured uterus, 4.7% for postpartum sepsis, 3.6% for preeclampsia/eclampsia, and 2.2% for abortion Stillbirth and very early neonatal death rate (indicator 7) The precise 7th EmOC indicator is the intrapartum and very early neonatal death rate, designed to reflect the quality of intrapartum care. No benchmark or maximum acceptable rate has been determined. It was not possible to calculate this indicator because most registers and logbooks did not differentiate between fresh and macerated stillbirths; furthermore, we were unable to select for infants who weighed 2500 g or more. The definition of very early neonatal death was a death that occurs within the first 24 hours of life but, again, this was not possible to adhere to because the majority of mothers were discharged approximately 6 hours post-delivery. Thus, we calculated a death rate that combined stillbirths and neonatal deaths occurring before the mothers discharge from the facility (Fig. 3). Table 3 Percentage of expected births attended in all facilities and by region, Ethiopia Population a,b No. of expected All facilities births (CBR*pop) c No. of births attended in facilities Expected births, % No. of births attended in facilities Expected births, % National Tigray Affar Amhara Oromiya Somali B-Gumuz SNNP Gambela Harari Addis Ababa Dire Dawa Abbreviations: B-Gumuz, Benishangul-Gumuz; CBR*pop, crude birth rate population; EmOC, emergency obstetric care; SNNP, Southern Nations, Nationalities, and Peoples. a Source of population estimates: Ref. [10]. b Population of special enumeration areas (96570) is included in national total but does not appear in any of the regional population totals. c Crude birth rate=35.7 per 1000 population for national, Harari, Addis Ababa, and Dire Dawa. For all other regions, crude birth rate =37.3 per 1000 population. Source of crude birth rates: Ref. [10].

4 104 K. Admasu et al. / International Journal of Gynecology and Obstetrics 115 (2011) Fig. 2. Met need for EmOC (the proportion of direct obstetric complications treated) in and non- by region, Ethiopia Abbreviations: B/ Gumuz, Benishangul-Gumuz; EmOC, emergency obstetric care; SNNP, Southern Nations, Nationalities, and Peoples. The rates ranged, by region, from 94 deaths per 1000 deliveries in Benishangul-Gumuz to 4 in Somali. Undercounting was clearly an issue in some of the regions, including Somali. Most deaths were recorded as stillbirths so many, in fact, that we believe some very early neonatal deaths were misclassified as stillbirths Proportion of maternal deaths that are due to indirect causes (indicator 8) There is no recommended level for this indicator, which was included to highlight the non-obstetric interventions that are needed in addition to EmOC to reduce maternal mortality. Nationally, based on the 685 documented maternal deaths, the proportion of all maternal deaths with indirect causes was 21%, whereas 69% had direct causes and 10% had unknown causes. Table 5 shows the percentage of indirect deaths for the regions, which ranged from 7% in Addis Ababa to 48% in Benishangul-Gumuz. The primary indirect causes of death were malaria, anemia, and HIV-related causes. 4. Discussion The present survey of obstetric service availability in Ethiopia might be said to represent the gold standard of such surveys, owing to 3 factors. First was the level of commitment of the Federal Ministry of Health to improving maternal and neonatal mortality, and Fig. 3. Stillbirth and very early neonatal death rates in all facilities by region, Ethiopia Abbreviations: B/Gumuz, Benishangul-Gumuz; SNNP, Southern Nations, Nationalities, and Peoples. achieving MDGs 4 and 5. Second, there were especially high levels of collaboration among the relevant partners governmental, UN, and technical agencies. Third, there was a generous level of funding, which eliminated the need to cut corners. This resulted in a high level of cooperation from the facilities surveyed, a very high level of quality control, and the ability to include the geocoding of facilities. Although the total cost exceeded US$1 million, the quality and scope of data available for planning and later evaluation are invaluable. The survey found that the quality and availability of EmONC in Ethiopia is well below recommended levels, which contributes to a level of maternal mortality estimated to be among the highest in the world. Achieving MDGs 4 and 5 will not be easy. Ethiopia shares with many low-income countries the challenges of limited resources, weak infrastructure (especially roads), and a shortage of health personnel. Ethiopia also has particularly challenging terrain and isolated communities requiring solutions from sectors in addition to the health sector. The Federal Ministry of Health and partners have already taken the following actions to address problems identified: prioritizing maternal and newborn mortality reduction in the national health plan; participation in district- and regional-level planning workshops where planning was based on district- and regional-level assessment data; procurement of magnesium sulfate for 125 hospitals and 800 health centers, development of a distribution plan by the Pharmaceutical Fund Supply Agency, and clinical guidelines, training in their use, and monitoring of clinical cases; negotiation with the Red Cross to build 26 centers with blood banks; joint programming among Table 4 DOCFR in all facilities and by region, Ethiopia All facilities No. of women with direct complications a No. of maternal deaths DOCFR, % b No. of women with direct by direct cause a complications a No. of maternal deaths by direct cause a National Tigray Amhara Oromiya Addis Ababa SNNP B-Gumuz Affar, Gambela, Somali Dire Dawa, Harari DOCFR, % b Abbreviations: B-Gumuz, Benishangul-Gumuz; DOCFR, direct obstetric case fatality rate; EmOC, emergency obstetric care; SNNP, Southern Nations, Nationalities, and Peoples. a Direct complications and direct causes of maternal death include: prepartum hemorrhage; postpartum hemorrhage; obstructed/prolonged labor; ectopic pregnancy; severe abortion complications; retained placenta; ruptured uterus; postpartum sepsis; severe pre-eclampsia/eclampsia. Excludes other direct complications. b DOCFR=number of maternal deaths with direct causes/number of women with direct complications.

5 K. Admasu et al. / International Journal of Gynecology and Obstetrics 115 (2011) Table 5 Percentage of maternal deaths with indirect causes in all facilities and in by region, Ethiopia the UN partners and World Bank guided by results of the baseline assessment; training district health managers in planning and monitoring/evaluation in which they made use of facility-specific factsheets based on the assessment data; government-organized advocacy activities in March April 2010 around the theme that no mother should die giving life; and rapid expansion of infrastructure with construction of new general and primary hospitals, and a goal of 3200 health centers and health posts many of which have been completed. The following are already in the planning and development stages: training of 2000 nurses in BEmOC over the next 3 years; reactivation of maternal death audit; incorporation of the signal functions as part of clinical monitoring; and upgrading health centers so that all have running water Limitations All facilities All maternal deaths a Maternal deaths with indirect causes, % b All maternal deaths National Tigray Affar Amhara Oromiya Somali B-Gumuz SNNP Gambela Harari Addis Ababa Dire Dawa Maternal deaths with indirect causes, % Abbreviations: B-Gumuz, Benishangul-Gumuz; EmOC, emergency obstetric care; SNNP, Southern Nations, Nationalities, and Peoples. a Includes all recorded maternal deaths in facilities, regardless of cause, including maternal deaths with unknown causes. b Includes maternal deaths due to malaria, anemia, HIV/AIDS, and other indirect causes. Although designed to be a census of hospitals and health centers, some factors intervened to challenge that. The lists of facilities provided by the al Health Bureaus were incomplete; some facilities were still under construction, some hospitals turned out to be health centers, and some health posts were still being upgraded to be health centers. In some cases, the actual names of the facilities did not match the names on the list. From the initial list of 830 facilities, 110 were removed and 86 were added. Coverage of facilities was incomplete in Somali region, where only 11 of 26 facilities were visited. In Addis Ababa, only licensed facilities were visited, and others declined to provide complete data. Thus, our estimates of availability and utilization of EmONC are underestimates. Within facilities, records of deliveries, complications, and deaths are often incomplete. Incompleteness of death records led to 10% of causes of death remaining unknown, which may have caused underor overestimation of some causes. The pregnancy status of women dying from non-obstetric causes may not have been recorded, leading to underestimation of indirect deaths. Furthermore, early neonatal deaths are sometimes recorded as stillbirths and it is evident that a few regions seriously underreported maternal deaths and both stillbirths and early neonatal deaths Recommendations It is recommended that: geocoded spatial analyses are used to rationalize decisions regarding location of new or upgraded facilities and to develop referral systems; the availability of EmONC is increased, gaps in existing facilities are filled so that they are fully functional EmONC facilities, and new EmONC facilities are constructed only where none exists; the quality of EmONC is improved through a variety of standardized quality improvement techniques; human resource shortages are addressed through in-service training, taskshifting and sharing, rational assignment to posts, and increasing the output of clinicians; the demand for EmONC services is increased through community awareness and improved referral services; and the EmOC indicators are incorporated into the national health management information system and used to monitor progress. Acknowledgments The research on which the present paper was based was technically supported and funded by UNICEF, the WHO, and UNFPA. The Federal Ministry of Health and the al Health Bureaus facilitated access to all facilities. Jhpiego and Ipas assisted with training of data collectors. AMDD provided technical assistance throughout the project with support from the Bill and Melinda Gates Foundation. Conflict of interest The authors have no conflicts of interest. References [1] WHO, UNICEF, UNFPA, AMDD. Monitoring Emergency Obstetric Care: a Handbook. Geneva: WHO; [2] Keyes EB, Haile-Mariam A, Belayneh NT, Andualem GW, Pearson L, Abdullah M, et al. Ethiopia's assessment of emergency obstetric and newborn care: Setting the gold standard for national facility-based assessments. Int J Gynecol Obstet 2011;115(1): [3] Bailey P, AMDD Working Group on Indicators. Program note: Using UN process indicators to assess needs in emergency obstetric services: Bolivia, El Salvador and Honduras. Int J Gynecol Obstet 2005;89(2): [4] AMDD Working Group on Indicators. Program note: using UN process indicators to assess needs in emergency obstetric services: Morocco, Nicaragua and Sri Lanka. Int J Gynecol Obstet 2003;80(2): [5] Averting Maternal Death and Disability Working Group on Indicators. Averting maternal death and disability. Program note. Using UN process indicators to assess needs in emergency obstetric services: Pakistan, Peru and Vietnam. Int J Gynecol Obstet 2002;78(3): [6] AMDD Working Group on Indicators. Program note. Using UN process indicators to assess needs in emergency obstetric services: Bhutan, Cameroon and Rajasthan, India. Int J Gynecol Obstet 2002;77(3): [7] Paxton A, Bailey P, Lobis S. The United Nations Process Indicators for emergency obstetric care: Reflections based on a decade of experience. Int J Gynecol Obstet 2006;95(2): [8] AMMD. AMDD Needs Assessment Toolkit. needs-assessments Published. [9] FMOH, UNICEF, UNFPA, WHO, AMDD. National Baseline Assessment for Emergency Obstetric and Newborn Care: Ethiopia, Final Report; [10] MOH. Ethiopian 2007 Census: Health and Health-related Indicators. Addis Ababa: MOH; 2007.

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