Maternal Newborn and Child Mortality and Midwifery Education in Ethiopia- By Meseret Desta Haileyesus

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• Maternal Health and Midwifery in Ethiopia

• Meseret Desta Haileyesus
• (SMW,BsN BA,MPH)
• Office of Global Health, University of Alberta
• December 2, 2013

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Objective

• To share an overview of the general situation of
  Maternal health and midwifery education in
  Ethiopia.

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Presentation outline

• Introduction
• Maternal and Newborn health problem
• Contributing factors for Maternal death
• Referral system
• Midwifery Education in Ethiopia
• Challenges of Midwifery students
• Challenges of overall Maternal and Child Health
  care
• Recommendations
• Conclusion
• References

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Background

• Ethiopia is Africas oldest independent country.
• Covering 1,104,300 square kilometers
• Borders with 6 countries
• Geographical diversity ranging from 4,550m above
  sea level to 110m below sea level.
• The predominant climate type is tropical monsoon

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Ethiopia

• Total population of 79.8 million
• 83.6 rural
• 44 are under 15 years
• 3 over age of 65 years
• Total fertility rate (number of children per
  woman) 4.8
• Annual population growth rate is 2.6.

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Women age 1519 who are mothers or currently pregnant 12
Pregnant women who received antenatal care from a skilled provider 34
Births assisted by a skilled provider 10
Births delivered in a health facility 10
Children 1223 months fully vaccinated 24
Postnatal 7
The maternal mortality ratio for Ethiopia is 676 deaths per 100,000 live births.
Neonatal mortality 37/1000 live births
Infant mortality 59 /1000 live births
Under-five mortality 88 /1000 live births
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Introduction

• Ethiopia is one of the 189 countries that signed
  the Millennium Declaration. The UN Millennium
  Development Goals (MDG 4 and 5) calls for
  Ethiopia to reduce child and Maternal morality by
  a two-third and three-fourth respectively by the
  year 2015.

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• Ethiopia is one of the six countries that
  contribute to about fifty percent of the maternal
  deaths the others being India, Nigeria,
  Pakistan, Afghanistan and the Democratic Republic
  of Congo.

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Maternal and Newborn health problems

• MMR 676/100,000, it is still among the highest in
  the world (2011 EDHS)
• The major causes of maternal death
• Obstructed/prolonged labor,
• Ruptured uterus ,
• Severe pre-eclampsia/ eclampsia ,
• Malaria,
• Complications from abortion
• The majority of maternal deaths occur in the
  early postpartum period, more than half of which
  take place within a day of delivery.

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Newborn Health Status

• Remarkable reduction in infant and under-5
  mortality rate (1990 - 204/1000)..(2012 -
  68/1000)
• Little change in neonatal mortality 37/1000 (EDHS
  2011)
• Half of newborn deaths occur within the first 24
  hours after birth
• Three-quarters of all deaths occur within the
  first week of life
• Higher NMR in rural areas
• Major causes on neonatal mortality
• Infections (46)
• Birth asphyxia (25)
• Complications associated with LBW (17 )

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Estimated direct causes of neonatal deaths for
Ethiopia
Infection alone contributes to 46 of
neonatal death
( Source Facility based death report, FMOH, 2004)
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• 2005 6 of babies delivered by health
  professionals
• 2011 10 delivered by health professionals
• Urban 51
• Rural 5

Photo Indrias Getachew
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Contributing factors to maternal deaths

• Adolescent pregnancy
• HIV among pregnant women
• Malaria
• Malnutrition
• Harmful traditional practices(CARE, 2010).
• Maternal education, cultural norms.(Mekonnen Y.
  et al, 2003Shiferaw et al, 2013).

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Current Ethiopian government priority
strategies on Maternal Health

• The Ethiopia (HSDP-IV) strategies encompass
• Empowering women, men, families, and communities
  to recognize pregnancy-related risks, and to take
  responsibility for developing and implementing
  appropriate responses to them
• Ensuring access to a core package of maternal
  and neonatal health services, especially in rural
  areas where health facilities are limited
• Creating an environment supportive to safe
  motherhood and newborn health.

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The First Delay
Delay in deciding to seek care at the household

• Lack of information and inadequate knowledge
  about danger signals during pregnancy and labour
• Cultural /traditional practices that restrict
  women from seeking health care
• Lack of money

Male Involvement is Key
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The Second Delay

• Inability to access health facilities
• Poor roads and communication network
• Poor community support mechanisms

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The Third Delay

• Delay between arriving and receiving care at the
  health facility
• Inadequate skilled attendants
• Inadequate equipment and supplies
• Weak referral system

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• 80 of maternal deaths occur in the home and 50
  were the result of failed transportation to a
  health facility
• (The University of Addis Ababa determined in 2009)

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The death of a woman and mother is a tragic loss
to the family, community and nation as a whole.
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Commitment to reducing maternal deaths
GOAL
Reduce current MMR 267/100,000 by 2015
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Referral system
Referral is a two way process and ensures that a
continuum of care is maintained to patients or
clients. It is done from the community to the
primary care health service and to hospitals and
within hospitals and vice versa.
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• To improve referral systems
• Staff training ,referral guideline and service
  directory mandatory
• Transportation challenge need long term solution
  (roads improved, vehicle)
• The primary health care unit/hospitals periodic
  meeting on how to improve communication and
  feedback
• Establishment of feedback mechanism
• Health post should have portable stretchers that
  weight less and easy to handle-

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Midwifery Education in Ethiopia

• 18 universities that are offering midwifery
  training at BSc level of which 2 are private
  institutions.
• 27 regional colleges are training at the diploma
  level.
• The instructors, teaching materials and
  infrastructure have not grown proportionately to
  the rapid expansion of training institutions.

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• Most of the tutors do not have additional
  training as midwifery tutors rather they are
  assigned by FMOH and MOE to training
  institutions.
• 50 of the teachers were new graduates with no
  adequate skills and clinical experience as
  midwives to teach and evaluate/supervise students
• (2009 assessment of Midwifery Training
  Institutions UNFPA)

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• The tutor/student ratio is very high and the
  classrooms are overcrowded.
• (120 student in class)
• The health facilities for the practical area are
  very crowded with large numbers of students while
  the number of women delivering in the health
  facilities is less.

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Challenges of Midwives students(UNFPA 2012,State
of Midwife in Ethiopia)

• Unable to use computers and Internet
• Poor financial support
• Poor Infrastructure and non conducive setting of
  training center
• Shortage of training material
• Poor practicum
• Lesser quality of education

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• Motivation and retention
• lack of access to further education, low
  salaries, lack of supervision and lack of
  opportunities for career development are the main
  demotivating factors.
• 35 midwives have salary of (56-84)/month
• Only 7 of midwives have 200/month
• (UNFPA,2012 State of Midwifery)

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The presence of a midwife at birth can mean the
difference between life and death. (UNFPA
Executive Director 2009)
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Challenges on over all Maternal and Child
Health care Services

• Shortage of skilled midwives(117,989
  population)-WHO recommend 1 midwife for 5000
  population.(UNFPA 2012 ,states of Midwives)
• Turnover of health workers
• Inadequate availability of medical equipment
  (Mekonnen Y. et al, 2003 Shiferaw et al, 2013).

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Challenges Cont.

• The maternal health care facilities are poor in
  quality and poorly utilized
• Weak referral system which includes poor
  transportation and poor communication

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• Women are less informed about their health
  needs(most of the rural women are illiterate)
• There are inadequate and inaccurate data to
  evaluate maternal health care and no continuous
  maternal health care monitoring system

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Existing opportunities for intervention

• Government Commitment
• Supportive policy environment
• The Ethiopian government has created steps to
  lower the rates of maternal death. (30,000 HEW
  deployed).
• Commitment among HEW and Midwives

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Recommendations

• Reducing maternal mortality requires coordinated
  long-term efforts.
• Building quality improvement partnerships between
  health workers and communities
• Educating communities to support women and
  newborns through pregnancies, safe births, and
  postpartum periods, including women living with
  HIV/AIDS

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Recommendations cont..

• Strengthen the local health institutions and the
  referral system
• Increasing the number of Midwife trainers, and
  the quality of their training
• 30 midwives practicing with out licensure.
• Ministry of Health and Education offices ensure
  tutors should being assigned to teach have at
  least 2 years clinical experience.

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Recommendations cont..

• Ensure adequate and appropriate equipment,
  medications and supplies
• Improving women education and household economic
  status(health and nutrition improved)
• Integrating prevention of mother-to-child
  transmission of HIV services into all aspects of
  MNCH care, from family planning and postpartum
  care to ongoing care of HIV-exposed infants.

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Recommendations cont..

• Operational research needed to examine system
  level factor population access to MNCH services,
  content and quality ,assessing competency and
  preparedness of Health workers and HEW can
  provide use full information for programming.
• The Cessation section delivery in Addis Ababa
  exceeded to WHO recommendation(20) this can have
  effect on maternal and new born health.
  Investigation need for reason for high rate in
  Public and private facilities in Addis.

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Recommendations cont..

• Monitoring and evaluation of the services should
  be strengthen
• Address the low skill birth attendant rate by
  expanding ANC,PNC and family planning services
• At community level, health extension workers will
  be equipped with mobile phones, radios, and
  motor-ambulances, to ensure the referral system
  from community level to facilities.

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Can these help the country to improve coverage,
and quality of services?......
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• We are optimistic that goal of reducing child and
  maternal mortality is achievable because we have
  seen Ethiopia achieve a more than 40 percent
  reduction in child mortality among children under
  five in the last five years.
• We have seen sub-Saharan Africa achieve a 39
  percent reduction.

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Conclusion

• Maternal health problems are often not
  predictable, can be dealt with at the community
  level
• Most deaths are avoidable, as the health-care
  solutions to prevent or manage complications are
  well known.

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• There is ample opportunity to improve maternal
  health
• Reduce the likelihood that a women become
  pregnant
• Reduce the likelihood that pregnant women will
  experience a serious complication of pregnancy
• Improve the outcome of women with complication

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References

• Road Map for Accelerating the Reduction of
  Maternal and Newborn Morbidity and Mortality in
  Ethiopia 2012-2015, July 2012, FMOH
• FMOH et al. National baseline assessment for
  emergency obstetric and newborn care, 2008.
• Ethiopian Midwives Associations registration
  database for 2011/12
• Ethiopia Demographic and Health Survey 2011
  MEASURE DHS - ICF Macro.
• Health Sector Development Program IV. 2010- 2015
  Addis Ababa, 2011.
• International Federation of Midwives (2010).
  Strengthening midwives globally

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• Thank you