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Lifesaving Emergency Obstetric Services Are Inadequate in South Girma et al. BMC Health Services Research 2013, 13:459 http://www.biomedcentral.com/1472-6963/13/459 RESEARCH ARTICLE Open Access Lifesaving emergency obstetric services are inadequate in south-west Ethiopia: a formidable challenge to reducing maternal mortality in Ethiopia Meseret Girma1, Yaliso Yaya2,4*, Ewenat Gebrehanna3, Yemane Berhane3 and Bernt Lindtjørn2 Abstract Background: Most maternal deaths take place during labour and within a few weeks after delivery. The availability and utilization of emergency obstetric care facilities is a key factor in reducing maternal mortality; however, there is limited evidence about how these institutions perform and how many people use emergency obstetric care facilities in rural Ethiopia. We aimed to assess the availability, quality, and utilization of emergency obstetric care services in the Gamo Gofa Zone of south-west Ethiopia. Methods: We conducted a retrospective review of three hospitals and 63 health centres in Gamo Gofa. Using a retrospective review, we recorded obstetric services, documents, cards, and registration books of mothers treated and served in the Gamo Gofa Zone health facilities between July 2009 and June 2010. Results: There were three basic and two comprehensive emergency obstetric care qualifying facilities for the 1,740,885 people living in Gamo Gofa. The proportion of births attended by skilled attendants in the health facilities was 6.6% of expected births, though the variation was large. Districts with a higher proportion of midwives per capita, hospitals and health centres capable of doing emergency caesarean sections had higher institutional delivery rates. There were 521 caesarean sections (0.8% of 64,413 expected deliveries and 12.3% of 4,231 facility deliveries). We recorded 79 (1.9%) maternal deaths out of 4,231 deliveries and pregnancy-related admissions at institutions, most often because of post-partum haemorrhage (42%), obstructed labour (15%) and puerperal sepsis (15%). Remote districts far from the capital of the Zone had a lower proportion of institutional deliveries (<2% of expected births compared to an overall average of 6.6%). Moreover, some remotely located institutions had very high maternal deaths (>4% of deliveries, much higher than the average 1.9%). Conclusion: Based on a population of 1.7 million people, there should be 14 basic and four comprehensive emergency obstetric care (EmOC) facilities in the Zone. Our study found that only three basic and two comprehensive EmOC service qualifying facilities serve this large population which is below the UN’s minimum recommendation. The utilization of the existing facilities for delivery was also low, which is clearly inadequate to reduce maternal deaths to the MDG target. * Correspondence: [email protected] 2Centre for International Health, University of Bergen, Bergen, Norway 4Arba Minch College of Health Sciences, Arba Minch, Ethiopia Full list of author information is available at the end of the article © 2013 Girma et al.; licensee BioMed Central Ltd. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Girma et al. BMC Health Services Research 2013, 13:459 Page 2 of 8 http://www.biomedcentral.com/1472-6963/13/459 Background functions): administration of parenteral antibiotics, par- The fifth Millennium Development Goal (MDG 5) is to enteral oxytocic drugs, parenteral anticonvulsants for reduce maternal mortality by 75% between 1990 and pre-eclampsia, manual removal of retained placentas, re- 2015. Although there are good tools available to help re- moval of retained products of conception and assisted duce maternal deaths [1], the limited availability and vaginal delivery (vacuum extractions or forceps deliveries) poor quality of services cause nearly 300,000 maternal [8]. Institutions providing comprehensive EmOC should deaths in the world every year, with approximately 85% also be capable of performing caesarean sections, blood of the 287,000 global maternal deaths taking place in transfusions and services provided by the basic EmOC both Sub-Saharan Africa (56%) and southern Asia (29%) institutions. [2]. In 2008, more than half of all maternal deaths in the The findings of an assessment regarding the avai- world occurred in six countries: Afghanistan, Demo- lability, quality and distribution of EmOC services is cratic Republic of the Congo, Ethiopia, India, Nigeria important for health professionals and policymakers in- and Pakistan [3], with most of these preventable and un- volved in maternal health services. With high maternal acceptable deaths occurring around delivery or a few mortality rates and a mostly rural population, it is im- days after [4]. Bleeding during pregnancy and birth, portant to evaluate emergency obstetric care provided at obstructed and prolonged labour and pregnancy-related public health institutions in Ethiopia. hypertension represent the leading causes of deaths A recent study has shown there are too few health in- among women of reproductive age in resource-poor stitutions providing EmOC to meet the UN standards of countries [5]. at least five (four basic and one comprehensive) EmOC The maternal mortality ratio (MMR) for Ethiopia was institutions per 500,000 population in Ethiopia [9]. Only 1,061 (665–1,639) in 1980, 968 (600–1,507) in 1990, 937 7% of deliveries took place in institutions, including only (554–1,537) in 2000 and 590 (358–932) in 2008 [3]. 3% in institutions that routinely provided all signal func- Nevertheless, the results of the 2011 Demographic and tions. Six percent of women with obstetric complications Health Survey (DHS) revealed that there has been little were treated in health institutions, whereas only one- progress in reducing maternal mortality [6]. The DHS half of these women were treated in fully functional estimate of the MMR for 2011was 676 (541–810) per comprehensive EmOC facilities [9]. The study concluded 100,000 live births. A study has also showed that in sub- that far too few public institutions in Ethiopia meet the Saharan African countries, the progress towards achie- indicators set by the UN standards. ving MDG5 has been slow because of a poor quality of Ethiopia therefore faces many challenges, not only be- care, low access, inadequate skilled personnel and finan- cause of a limited number of adequately functioning ob- cial barriers to care [3]. stetric facilities, but also because of its large population The WHO recommends the use of process indicators and mountainous topography, with large parts of the on emergency obstetric care (EmOC) facilities to assist populations living in remote areas. We conducted this in monitoring the progress in maternal mortality re- study to assess the availability (coverage), quality (func- duction efforts, which are considered necessary for tionality) and utilization of emergency obstetric care fa- planning, implementing and monitoring initiatives to cilities in Gamo Gofa in south-west Ethiopia. improve maternal health [7]. Unfortunately, there is li- mited evidence regarding how these institutions are dis- Methods tributed, how well the existing facilities perform and Setting how many people use them in Gamo Gofa, Ethiopia. The study was conducted in the Gamo Gofa Zone in The investment in maternal health programmes can be south-west Ethiopia (see map in Figure 1). Nearly 1.7 evaluated by measuring input indicators (midwifery million people live in the area, with 90% living in rural training), process (the number of midwives posted) and communities. The Zone has 15 woredas (districts) and outcomes (the uptake of skilled delivery care). However, two town administrations, each being directly adminis- the assessment of impacts such as the reduction in mor- tratively responsible to the Zone. However, people in the tality in a community can show the effects of long-term surrounding districts of the towns, as well as the towns interventions. themselves, use the health facilities/services/ in these The availability and use of emergency obstetric care towns. The Zone represents three climatic zones (cold, services is important for reducing maternal morbidity temperate and hot), where most of the people live in and mortality. Based on the capacity to provide lifesa- highlands 2,000 metres above sea level and practice sub- ving emergency obstetric procedures, a health institution sistence farming. There are few all-weather roads in the can be classified as basic or comprehensive emergency area, although most of the population lives in the high- obstetric care facility [8]. Basic EmOC institutions are lands without access to roads. Health care is provided by expected to provide the following six services (signal three hospitals, 63 health centres and by rural health Girma et al. BMC Health Services Research 2013, 13:459 Page 3 of 8 http://www.biomedcentral.com/1472-6963/13/459 Figure 1 Administrative map of Gamo Gofa Zone and its Woredas, south-western Ethiopia, 2010. extension workers in 483 kebeles, which are Ethiopia’s caesarean sections. The programme aims to support lowest administrative units, with an average coverage of public health services to help reduce maternal and neo- 1,000 households (population of 5,000). Hospitals are ex- natal deaths [10], and is primarily a support to govern- pected to provide comprehensive emergency obstetric ment institutions with training, supervision and providing care, while the health centres are expected to provide the institutions with basic equipment. Thus, while the basic emergency obstetric care. Due to limited access to population in 2007 had only one hospital capable of doing hospitals, senior staff (health officers) are given minimal comprehensive EmOC for approximately 1.7 million training, and provide services such as caesarean sections people, the services such as caesarean section delivery had in some health centres. Four (6%) of the health insti- improved to three hospitals and two health centres (one tutions in the area are accessible by asphalt roads, 21 fa- institution per 350,000 people) by 2010.
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