Save the Mothers Initiative

Project Title: Save the Mothers Initiative Program.

Project Area: Ambo district –Ambo Hospital, Chaliya district –Ejaji health center, and Noono district-  Shenen health center.

Project Coordinator: Solomon Kumbi, MD, Ayele Debebe, MD

Background Information

ESOG in collaboration with FIGO and Oromia Regional Health Bureau was running “Save the Mothers Project – Ethiopia” since June 1998. The project area is west Shoa zone, 125km west of the capital Addis Ababa. When the project is launched, west Shoa zone had 24 districts with a population of about 2.6 million.

Currently, the zone is divided into two for administrative purposes. The new west Shoa zone has:

The data show that health service coverage is very low. Similarly, utilization of the existing meager health facility is minimal. These may indirectly indicate that quality of RH services is also poor.

Objective

Decreasing maternal mortality and morbidity through making EmOC accessible to women living in the project area.

Strategies

1)         Community mobilization to improve involvement and develop sense of ownership

2)         Dissemination of achievement

3)         Assurance of continued availability of EmOC

4)        Continued supervision, monitoring and evaluation of the project by coordinators but with equal involvement of regional health bureau and hospital committee in the activities throughout the year 2003. This was thought to gradually escalate involvement of the regional health bureau and zonal health department in monitoring and supervision of the project supported activities and make the hand over easier.

 Activities

1)      Establishment of coordinating committees at the regional, zonal and hospital levels.

2)      Periodic meetings with hospital, zonal and regional committees about the progress of activities of the project.

3)      Capacity building of the three project health institutions,

3a) Supply of essential equipments for caring out basic and comprehensive EmOC based on initial assessment.

3b) Training of seven physicians on comprehensive EmOC.

3c) Training of 37 midwives/nurses/health assistants from Ambo hospital, Ejaji health center and Shenen health centers as well as from other health institutions of the zone on basic EmOC.

3d) Improved recording and reporting as seen on tables 2, 5, 7 below.

3e) Better referral system and maternal mortality audit.

4)      Regular supervision, technical assistance and supply of needs by the coordinating bodies (ESOG).

5)      Community mobilization, participation and sense of ownership.

6)      Strong collaboration with GOs and NGOs in the area.

7)      Dissemination of the project output to the stakeholders, the community at large, Oromia regional health Bureaus, the health units, local leaders, and responsible government organizations.

Achievements

1. The number of cases managed in the hospital is progressively increasing with case fatality rate of each complication   decreasing.
2. Early problem detection, management and/or referral is improved.
3. Interruption of comprehensive as well as basic emergency obstetric care is minimized because obstetrician and/or trained Gps are always available. The same is true for basic EmOC at the health centers.
4. Clean and properly highlighted and complete registration has been seen throughout the project time with marked improvement from previous.
5. Sensitization of the community leaders, health management team and hospital staff on EmOC situation is achieved.
6. Considering all the positive gains from the project and to make sure the activities and good trends are continued the society appointed site level and central project coordinators.
7. The society believes that even though a significant difference had been achieved in minimizing phase three delays, little had been done to minimize phase I and II delays. Therefore, specific attention is to be given to creating community awareness, birth preparedness, danger signs of pregnancy and childbirth. Before launching phase out activities, the executive committee of ESOG held a half-day long meeting with Ambo hospital management team, zonal health bureau, and zonal administrative bodies as well as community leaders and discussed on the past achievement, pitfalls and future stakeholders role.

A. Clinical activities

1. Ambo hospital:

Currently, Ambo hospital provide comprehensive EmOC 24 hours a day and 7days a week. The hospital has 10 general practitioners, one Obs/Gyn, one surgeon, one pediatrician, four midwife nurses, one anesthetic nurse, 32 clinical nurses and auxiliary staffs. Hospital delivery is almost the last resort in the area, majority of mothers arriving only after prolonged stay at home in late second stage of labor, with diagnosis of obstructed labor and about 4% after developing uterine rupture.

Table 1. Deliveries attended at Ambo hospital by mode of delivery, year 1998-2003

The table shows that total number of deliveries in the hospital as well as complicated cases that require more skilled interventions is progressively increasing. The level of intervention has increased from 16% in 1998 to 36% in 2003. The number of cesarean sections and laparotomy for uterine rupture also increased by more than five fold. The number of referrals is kept to the minimum.

It is important to note that 188 (32.9%) of the 572 cesarean sections and 42 (31.3%) of the 134 laparotomies for uterine rupture done until the end of March 2004 were performed by GPs trained by the project.

Table 2. Obstetric complications and maternal death, 1998-2003.

Table 3. Maternal deaths in Ambo hospital, 1998-2003

As can be seen from tables 2 and 3, the number of complications managed in the hospital is increasing markedly over the last five-project years as compared to the beginning. Even though case fatality is generally very high due to late arrival, it has decreasing by nearly 50%.

This could be attributable to the decrease in phase III delay, staff training, equipment and drug supply, better referral system although cause and effect relations is difficult to set due to multiple variables. All 16 deaths in the year 2003 had been reviewed, and 13 occurred within 12 hours of arrival of which 10 were in the first 2 hours of arrival to the hospital. The most common cause of death was obstructed labor/uterine rupture. 

2. Ejaji health center

Table 4. Deliveries attended at Ejaji health center by mode of delivery, 1998-2003.

Table 5. Obstetric complications, 1998-2003

Number of complications detected and reported is increasing progressively. They also started to manage cases of incomplete abortion, puerperal sepsis and ventouse delivery which they were referring previously.

3 .Shenen health center

Table 6. Deliveries attended at Shenen health center by mode of delivery, 1998-2003.

Table 7. Obstetric complications, 1998-2003.

The number of deliveries at Shenen health center is increasing progressively. In addition, the number of complications detected had been increasing progressively over the past four years. Similar to Ejaji health center, they also started to mange cases, which they had been referring previously like incomplete abortion, puerperal sepsis, and ventouse delivery. The problem that every one notice at this health center is the very low utilization of  EmOC services by the local community (123,305  catchment population , institutional delivery rate of 2.3%).

All the tables give indirect evidence on improved recording and reporting after the implementation of the SMP project compared to records before, i.e, 1998. 

Supervision

Regular supervision and monitoring was made. Supervision activities included on the job observation of procedures as well as review of recording and reporting. Specific corrective comments were given at the site. During supervision not only the heath units are visited but discussion is also held with the health managers and women's affair representatives.

Community awareness activities

Workshop on how to improve Emergency Obstetric Care Service Utilization and Community Awareness in SMP-Ethiopia Project Areas:

A total of 26 participants from Ambo and Nono woredas attended the workshop held in Ambo. In Chelia, same workshop was conducted with 20 participants. The objective of the workshop was to improve EmOC service utilization by building community awareness. The participants included Heads and MCH coordinators of the zonal health department and woreda health offices, zonal and woreda administration representatives, zonal and woreda women’s affairs Heads, directors and members of the project health institutions, TBAs and community opinion leaders.

Participants promised to stand behind ESOG and health personnel to fulfill the objectives of safe mother-hood.

National consultative meeting on " Save the Mothers Program "

The meeting was held on March 24, 2003, in Sheraton Addis, Ethiopia. Participants included representatives from MOH, UNICEF, WHO, Care-Ethiopia, Head of Regional health Bureau, members of reproductive health community, honorary members from ESOG, ESOG's executive committee and save the mothers project coordinators. Distinguished guests also included the current and past chairmen of Irish Obstetricians and Gynecologists Society.

It was concluded that there is a need for increasing availability of skilled attendance at delivery at community level. It was also noted that partnership and close collaboration with midwives, TBAs, government agencies and NGO's and community education is important to avert the high MMR in the country.

Community awareness creation on reproductive rights, danger signs of pregnancy and child birth, and family planning

The objectives of the community awareness meetings were:

·                    To create community awareness on danger signs of pregnancy and childbirth, and there by improve utilization of available health service.

·                    To explore health seeking behavior in order to determine ways by which women with obstetric complications can make use of the available services

·                    To have advocacy group and focal persons at the smallest administrative unit level (farmers association)

·                    To give knowledge on reproductive rights and the rights based approach to health services.

Women with leadership ability (women's representatives) were selected from each farmers’ associations. Community conferences were organized at the three project districts.

The topics covered at the three sessions included:

1)      Sexual and reproductive rights, and rights-based approach to health services by chairperson of Oromia region women representatives forum

2)      The birthing process and its difficulties was discussed by a nurse midwife

3)      Danger sings of pregnancy and child birth by one of the project coordinators

4)      Family planning advantage and available choices were discussed.

5)      Finally, the need for birth preparedness has been discussed.

The meetings provided opportunities to pass on basic messages at the grass root level. It also showed as to why the community doesn't make delivery at health unit their first option. Even though immediate impact might not be visible soon, by minimizing the limiting factors and increasing awareness in danger signs of pregnancy and childbirth, it is likely to improve utilization of the available health services.

A follow-on meeting was conducted with participants which are actively working in their localities, health managers and administration officials.

Advocacy film

Building public knowledge and opinion on sexual and reproductive health and rights based on experiences obtained from the grass root is expected to provide first-rate information to the community. It will also avoid the paternalistic, ready-made approach of many projects. For this reason an advocacy film entitled ‘Adden Addee’ which literally means ‘the Cry of Mama’ to address this issue to the reproductive health community in the Ethiopian setting was produced with the FIGO social action matching fund.

A study to explore reasons for under utilization of available EmOC  services

A qualitative study to explore reasons for underutilization of EmOC services was carried out. see details in research outputs

IEC

Pamphlets on the five common causes of maternal mortality in developing countries was prepared and distributed in the zone through the health institutions and women’s affairs representatives. The brochures were prepared in the local language with minimal use of medical jargon so that every body could read and understand the message.

Stakeholders’ and ESOG executive committee meeting on achivement and future activities of the project

Participants of the meeting were executive committee of ESOG including the president, SMP-Ethiopia project coordinators, zonal health management team, zonal administration representative, the three project area district administrators, community opinion leaders and women's affair office representatives.

Highlights of inception of the project, the activities carried out and the challenges encountered were presented by the project coordinators.

It was mentioned that here are favorable situations to reach the community at grass roots level because there are women's associations chairpersons and agricultural development agents in each kebeles.

It was also pointed out that training of health personnel should not only address skills, but also ethical points so that they will be caring and supportive during labor and delivery. In addition, to overcome accessibility problems, health stations and TBAs should be supported with training, material supply and capacity building.

Multi-sectored approach i.e health personnel, administrative bodies, women's affairs, teachers and others should work together to over come the problems.

J. Dissemination symposium

Dissemination symposium carried out during ESOG’s annual conference as precongress workshop on May 25, 2004.

Implementation of some of the activities have been postponed after the date set for phase out, December 31, 2003.

As per the communication with FIGO necessary preparation for the end term evaluation is underway.

Current Status: Phased out, March 2004.