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(Un)Safe Routes: Maternal Mortality and Ethiopia's Development Agenda

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(Un)Safe Routes: Maternal Mortality and Ethiopia's Development Agenda (Un)safe routes: Maternal mortality and Ethiopia’s development agenda by Ruth Jackson, BA BLitt (Hons) Submitted in fulfillment of the requirements for the degree of Doctor of Philosophy Deakin University July 2010 DEAKIN UNIVERSITY CANDIDATE DECLARATION I certify that the thesis entitled (Un)safe routes: Maternal mortality and Ethiopia’s development agenda submitted for the degree of Doctor of Philosophy is the result of my own work and that where reference is made to the work of others, due acknowledgment is given. I also certify that any material in the thesis which has been accepted for a degree or diploma by any other university or institution is identified in the text. FULL NAME…Ruth Ethel Jackson…………………………………………..…….. Signed……………………………………………………………………………….. Date…………………………....…………………………………………………….. i Acknowledgments In Australia, my introduction to International Development Studies began when I chose a new focus for my electives as a third-year undergraduate at Deakin University. Since being captivated with this new line of study, I followed it through a Bachelor of Letters, Honours and then a Higher Degree by Research. Dr Max Kelly assisted me with my original application to the university and then became my primary supervisor. My other supervisors were Dr Liz Eckermann and Dr Rohan Bastin. In 2007, I was accepted as a visiting student at Addis Ababa University Population Studies and Research Centre, headed by Dr Assefa Hailemariam. Dr Assefa was my pivotal contact in Ethiopia, and he facilitated many contacts and documents that enabled me to travel to Ethiopia to conduct research. Without naming everyone, but also to protect their privacy, people in the following organisations were prepared to give their time to be interviewed or to offer documents or reports in Ethiopia: Actionaid; Addis Ababa University; Apostolic Prefecture of Jimma-Bonga, especially the Social and Development Coordination Office in Jimma and other individuals who offered me great kindness and hospitality throughout my fieldwork in 2007; CARE International Ethiopia; Decha Woreda Health Desk; FAO; Lalmba Chiri Health Center; Ministry of Health Addis Ababa; Farm Africa; Kafa Development Association; Kafa Development Program; SOS Sahel; the Zonal Health Department and Statistics Office; and, many individuals at various health posts, health centres, clinics and Bonga Hospital in Kafa Zone. Thanks also to Habtamu Argaw from the WHO (previously from SUPAK). Christian Grassini contacted many people he knew in Ethiopia who made my stay more enjoyable. His friendship near the end of my stay in Ethiopia was crucial to my sanity. Through Christian, a contact at FAO Addis Ababa accessed a number of maps which was a major achievement given the difficulties I had trying to access maps in Kafa Zone where the printer at the mapping and statistical office was ‘non-functional’ despite a new printer cartridge brought from Australia. To the many women who graciously offered hospitality and allowed me to enter their homes to discuss their experiences of pregnancy and childbirth, I cannot express my gratitude in words. In almost all circumstances this was despite their poverty and difficult circumstances. Many of these women were coping on their own with their children. I will never forget their ability to smile and laugh despite their hardships. In spite of everything I had the feeling that life goes on and that we have much in common despite our cultural differences. Mike Watters has exceptional coffee making skills, and Jo and Jack assisted with technical problems over many years. My parents David and Rose Jackson and my brother Philip also provided support. Other friends including Lisa Lillee, Michelle Keen, Tony Bazeley, Bernard Goldman and Ella Rosso have shared the highs and lows. Alganesh Argaw and her family welcomed me into their home in Adelaide on many occasions; Alganesh and Dr Tilahun Afrassa (then Secretary of the Ethiopian Community Association SA Inc) translated my ethics documentation in Amharic. በጣም:አመሰግናለሁ:: Other HDR students and the off-campus library staff at Deakin University have been wonderfully supportive. Thanks Glenda. Cheers Murray. ii I met Elizabeth Reid at the ‘Africans in Australia and Outsiders in Africa’ Conference run by African Studies Association of Australasia and the Pacific in early 2008. Elizabeth’s longstanding commitment to the well-being of women and her thoughtful counsel really meant a lot to me. The Australian Federation of University Women (AFUW) provided funding for a female interpreter throughout my research in Ethiopia through a William and Elizabeth Fisher Scholarship Ethel McLennan Bursary. Although there were a few occasions when I had to work with male interpreters, most of the time I worked with a young woman whose first language was Kafficho, her second was Amharic and the third was English. Azeb and her siblings had not long lost their father, and were still mourning the recent loss of their mother. At times I felt our relationship was like that of a mother and daughter. Nevertheless, over the months we became firm friends and I was grateful to know her and her extended family who did everything possible to ensure my stay was enjoyable. We did a lot of walking and talking together and I hope the experience gave her extra confidence to achieve her goals in the future. Azeb and her sister Genet are now studying nursing. iii Abstract Of all the health statistics monitored by the World Health Organization (WHO), maternal mortality has the highest discrepancy between developing and developed countries. Maternal mortality and disability levels in many developing countries are similar to those of the more developed regions of the world at the late nineteenth century. The reduction of maternal mortality by three quarters by 2015 was endorsed as a Millennium Development Goal. Starting with the theory of international development and the presumption that biomedical health interventions will reduce maternal mortality and disability if governments devote resources to health care and delivery assistance, the thesis documents the need to take a more comprehensive perspective to understand the problems of maternal mortality to include social, cultural, economic and political determinants of health in addition to the transfer of health service interventions. It draws on the Three Delays model which emphasises the importance of delays between the onset of obstetric complications and its outcome and proposes that most maternal deaths are preventable with prompt and adequate medical interventions. This study employed qualitative techniques to determine how reproductive health, in particular the goal of reducing maternal mortality, fits into Ethiopia’s development agenda. In Kafa Zone in south-west Ethiopia, most women give birth with the assistance of their neighbour, mother, mother-in-law, or husband. Less than five percent of women give birth in a health institution or with the assistance of a trained health worker or trained traditional birth attendant. Using semi-structured interviews with key personnel in government and non-government organisations, in health institutions, and with women in rural and semi-urban areas in Kafa Zone, the research juxtaposes women’s experiences of birth at home with that in a ‘modern’ health care setting. It is likely that women who give birth at home feel ‘safe’ because that is where birth normally takes place and where they are supported by close relatives and neighbours. Women always feel it is ‘unsafe’ to go to a health facility because of the very real possibility they will die on the way. For this reason, a picture emerges of ‘unsafe’ childbirth denoting those births that are transferred to a health facility. The study confirms that as maternal health has been identified as a key development goal in Ethiopia, there is a need to consider social and cultural issues alongside biomedical health interventions. iv Table of Contents Acknowledgments...........................................................................................................................i Abstract…………........................................................................................................................iii List of photos ................................................................................................................................vi List of maps ...................................................................................................................................vi List of boxes ..................................................................................................................................vi List of tables..................................................................................................................................vii Abbreviations ..............................................................................................................................viii Glossary…….................................................................................................................................ix Chapter 1: The research background: Questions, objectives and theoretical considerations.................................................................................................................................1 1.1 The research background ...........................................................................................1 1.2 Research objectives....................................................................................................15
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