Maternal and Neonatal Mortality in Rural South Ethiopia: Comparing Mortality Measurements and Assessing Obstetric Care

2015 Maternal and neonatal mortality in rural south Ethiopia and neonatal mortality in ruralMaternal south Ethiopia Maternal and neonatal mortality in rural south Ethiopia: Comparing mortality measurements and assessing obstetric care Yaliso Yaya Balla Dissertation for the degree of philosophiae doctor (PhD) University of Bergen, Norway 2015 • Yaliso Yaya Balla Yaya Yaliso • www.uib.no Graphic design: Division of Communication, UiB ISBN: 978-82-308-2600-3 Print: AIT Oslo AS Maternal and neonatal mortality in rural south Ethiopia: Comparing mortality measurements and assessing obstetric care <DOLVR<D\D%DOOD Dissertation for the degree philosophiae doctor (PhD) at the University of Bergen Dissertation date: June 25th Dedication To mothers who die during pregnancy and childbirth in resource-limited settings without accessing essential obstetric services. “Pregnancy is not a disease but a normal physiological process that women must engage in for the sake of humanity. Whereas the elimination or eradication of disease is a rational and laudable endeavour, the same strategy cannot be applied to maternal mortality. There is no pathogen to control, no vector to eradicate. Women will continue to need care during pregnancy and childbirth as long as humanity continues to reproduce itself. Failure to take action to prevent maternal death amounts to discrimination because only women face the risk.” Carla AbouZahr (2003) Maternal and neonatal mortality in rural south Ethiopia 2015 Acknowledgements I gratefully acknowledge the Norwegian State Education Loan Fund and the Centre for International Health, University of Bergen for funding my study. I would also like to acknowledge the Gamo Gofa Zonal Health Department and Woreda Health Offices in Bonke, Arba Minch Zuria, Demba Gofa, and Derashe for the important supports during the fieldwork. I am grateful to the health extension workers who did the birth registry, as well as the supervisors and data collectors of all of the studies. Thanks to the academic and administrative staffs and management of Arba Minch College of Health Sciences for support. I wish to express my deepest gratitude to my supervisor Professor Bernt Lindtjørn. It has been a great blessing to have been under your supervision for a decade for MPhil and PhD studies. You have always shown me love and respect, while being strict to the things I should work and learn. I cannot have sufficient words to thank you for your dedicated and highly qualified support, amazingly quick feedbacks, and the fatherly understanding. Now I have the confidence to think critically and work independently. Had it not been your close guidance and understanding, this work would not have been successful. To my co-supervisor, Professor Ole Frithjof Norheim, I would like to sincerely thank you for your close supervision and professional guidance, especially during the write up. It is rare to find a person both intelligent and humble like you. Thank you co-authors of the studies in this thesis, Meseret Girma, Tadesse Data, Professor Yemane Berhane, Dr Ewenat Gebrehanna, and Kristiane Tislevoll Eide, for your important contributions. I learned much working with you all. I wish to express my sincere appreciation to the staff of the Centre for International Health, University of Bergen for all-rounded support and friendly environment. To Borgny Lavik, Unni Kvernhusvik, Ingvild Hope, Øyvind Mørkedal, Solfrid Hornell, thank you for facilitating all practical and logistical issues. Families of Solomon Haile, Eyob Nebiyu (Desta Taye), Senait Yigletu, Tadesse Washo, and all members of Shalom Coventant Evengelical Church in Bergen, thank you for the prayer and support. God bless you all. My appreciation goes to two special families in Bergen: Geremew Huluka and wife Mette Øxnevad, and Dr Skjalg Klomstad and wife Dr Grete, you two families showed me and my family a very specilal love and care. Special thanks! Yaliso Yaya Balla PhD Thesis i Maternal and neonatal mortality in rural south Ethiopia 2015 I owe my sincere gratitude to my best friend, asistant Professor Tuma Ayele, and his family for the support and encouregement even himself being in difficult situations. As your name itself mean ‟truth”, you are always committed to preserve faithfulness and integrity, and pay the resulting cost ─ the reason why I love you so much. Dr Degu Jerene, you are a brother who always guided me for improvements and here is part of the fruit; and as you often say: ‟the best is yet to come”. Brother Kebede Tefera, you are a person born to help and give love. I am grateful to you and Selu, your wife. Ato Kare Chawicha, former head of SNNPR Health Bureau and now minister d’etat, I am grateful to your understanding and encouragement. Dear friends Misikir Lemma, Mesay Hailu, Dr Eskinder Loha, Dr Daniel Gemechu, Endashaw Shibru, Taye Gari, Tigist Gebremichael, Berite Belete, Zemach Guma, Tadesse Data, Damenech Zewdie, Bahilu Merdikios, Amsalu Kusita, Selamawit Dagne, Endrias Olto, Demissie Admasu, Alemayehu Bekele, and Zekarias Erkola, I thank you and your families for the lovely friendship and encouragement. My father Yaya Balla and mother Batale Alaho, thank you for deciding to send me to school defying the harsh poverty. My brothers Yosef, Lukas, Petros, Bantirgu, and Belachewu, and sister Amenech, thank you for suppot and caring for our parents during my study. My late sister Almaz, may your soul rest in peace as you passed away when I prepared to submit this work. It will be so painful to go home where you are missing. Lame Legesse, Melesse Minota, Almaz Lema, without your economic support, I could not have even completed my primary education. Yehuala, Serawit, Enata, Habtamua, Aklile, and Manaye, God bless you. My wife Tigist (Boche), I can never thank you enough for your love, care, and hard work to support our subsitence while doing your own study, and reproducing beautiful kids. You are source of inspiration and reason of sucess in my life, next to God. My four little kids, two sons and two daughters, Yabets, Abigiya, Magnus, and the Angel on the way, thank you for your love and endurance. Love you so much and life is beautiful with you. I am grateful to the love and support from my mother in-law Azalech Wudneh, brothers in-law Solomon, Yonas, Yared, Dr Ketema, and Biniyam and sisters in-law Hirut, Hanna, Konjit, Selam and Mesay. Finally, and most importantly, God the Almighty, Alpha and Omega, thank you for favouring me. ‟ሁሉን ታደርግ ዘንድ ቻይ እንደ ሆንህ፥ አሳብህም ይከለከል ዘንድ ከቶ እንደማይቻል እኔ ያሊሶ አወቅሁ” (‟I, Yaliso, know that you can do all things, and that no purpose of yours can be thwarted”), Job 42:2. All I am and I have, it is because of you. Thank you God. Yaliso Yaya Balla PhD Thesis ii Maternal and neonatal mortality in rural south Ethiopia 2015 Summary Introduction: The aim of the Millennium Development Goals (MDG 4 and 5) is to substantially reduce maternal and child mortality in the world. However, information is limited in low-income countries to help oversee progress towards the MDG targets. In developed countries, quality data are obtained through routine vital registrations. Unfortunately, registry-based data are lacking or incomplete in most developing countries, and Ethiopia is no exception. As such, we had a scarcity of information on the level of maternal and neonatal mortality, as well as the coverage and quality of obstetric services in south Ethiopia. The information is important because the target for MDGs in 2015 and the preparation for the Sustainable Development Goals (SDGs) are fast approaching. Objective: The aim of the thesis was to measure and compare maternal and neonatal mortality and obstetric services through community- and facility-based methods in southern Ethiopia. Methods: We used four different methods to measure maternal mortality, and in one of these methods assessed one-year obstetric services in all health centres and hospitals in Gamo Gofa (population 1.8 million in 2010) in south Ethiopia. The methods were: 1) Between January and December 2010 health extension workers prospectively registered births and birth outcomes in 75 rural villages in three districts in south Ethiopia (population of 421,639 people) (Paper I); 2) In February 2011, we conducted a survey in 6,572 households that reported pregnancy and birth outcomes in the previous five years (2006-2010) out of a total of 11,920 households in 15 out of 30 randomly selected rural villages in the district of Bonke (Paper II); 3) Using the sisterhood method, we estimated the lifetime risk of pregnancy- related deaths and MMR through interviewing 8,503 adult siblings from the 15 kebeles where the survey for Paper II was conducted in Bonke (Paper III); and 4) We reviewed one-year institutional records on births, birth outcomes (maternal deaths), and signal functions of emergency obstetric care in all 63 health centres and three hospitals in Gamo Gofa. We then calculated the population coverage of obstetric care, the rate of skilled birth attendance, and the quality of obstetric service against the UN’s minimum standards (Paper IV). Yaliso Yaya Balla PhD Thesis iii Maternal and neonatal mortality in rural south Ethiopia 2015 Results: In 2010, we recorded 10,987 births and 53 maternal deaths (an MMR of 489 per 100,000 LBs, with 83% (44/53) of maternal deaths occurring at home. The MMR was associated with the education level of the father of the baby, access to driveable roads, and sickness of the mother during pregnancy (Paper I). In the household survey (Paper II), we enumerated 11,762 births and 49 maternal deaths (an MMR of 425 per 100,000 LBs), and of the maternal deaths, 87% (43/49) occurred at home. The poorest households and those with illiterate household heads had a higher MMR.

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