MNH Workshop Proceedings

Addressing Community Maternal and Neona-
tal Health in Ethiopia. Report from National

Scoping Exercise and National Workshop to In-
crease Demand, Accesses and Use of Commu-
nity Maternal and Neonatal Health Services.
May 2009
- L10K
John Snow, R&T
Inc. Ethiopia
Federal Democratic Republic of Ethiopian Society of Obstetricians &

The Last Ten Kilometers
Ethiopia Gynecologists
Ministry of Health ESOG
I| P a g e
Table of Contents
LIST OF TABLES AND FIGURES II

ABBREVIATIONS AND ACRONYMS III
EXECUTIVE SUMMARY 1
1.INTRODUCTION 4
1.1 BACKGROUND: .......................................................................................................................................................... 4
1.2 POLICY ENVIRONMENT: ............................................................................................................................................... 4
1.3 NATIONAL SCOPING EXERCISE ON THE COMMUNITY COMPONENT OF MNH .......................................................................... 7
2 MATERNAL AND NEONATAL HEALTH STATUS 8

2.1 MATERNAL OUTCOMES ............................................................................................................................................... 8
2.1.1 Causes of maternal deaths ........................................................................................................................... 9
2.1.2 Fistula—another major outcome of pregnancy ............................................................................................ 11
2.1.3 Service coverage to ensure maternal health................................................................................................. 11
2.2 NEONATAL OUTCOMES ............................................................................................................................................... 12
2.2.1 Service coverage to ensure neonatal health.............................................................................................. 14
3. HOME PRACTICES AND CARE SEEKING IN MNH 15

4. EFFORTS/EXPERIENCE TO IMPROVE MNH AT COMMUNITY/HOME LEVELS 17
4.1 HEALTH EXTENSION WORKER LEVEL ............................................................................................................................... 17
4.2 COMMUNITY LEVEL ..................................................................................................................................................... 19
4.3 FACILITY LEVEL .......................................................................................................................................................... 19
5. GROUP WORK: CONCLUSIONS AND RECOMMENDATIONS 21
ANNEX 1: LIST OF WORKING GROUP MEMBERS 31
ANNEX 2: WORKSHOP AGENDA 32
ANNEX 3: LIST OF WORKSHOP PARTICIPANTS 36
1
List of Tables and Figures
Tables
Table 1: National policy and strategic documents related with MNH 5
Table 2: Catchment population and nine month performance report of
HEWs (5) by region 19
Table 3: Priority interventions: status and barriers to implementation 24
Table 4: Strategic recommendations with priority intervention area by
level of care 29
Figures
Figure 1: Trend of Maternal Mortality Ratio in Hospitals, 1970 to 2009 8
Figure 2: Trend of Major Causes of Direct Maternal Deaths, 1982 to 2008 9
Figure 3: Mortality Rates for Neonatal and Prenatal periods 13
Figure 4: Causes of neonatal death 14
II
Abbreviations and Acronyms
AIDS Acquired Immune Deficiency Syndrome
AMTSL Active Management of Third Stage Labor
ANC Antenatal Care
BCC Behavioural Change Communication
BPCR Birth Preparedness and Complication Readiness
CBO Community Based Organization
CBRHAs Community Based Reproductive Health Agents
CC Community Conversation
CEmONC Comprehensive Emergency Obstetric and Neonatal Care
CFR Case Fatality Rate
CHAs Community Health Agents
CHWs Community Health Workers
CI Confidence Interval
CPR Contraceptives Prevalence Rate
DHS Demographic Health Survey
EDHS Ethiopian Demographic and Health Survey
EmOC Emergency Obstetrics Care
EmONC Emergency Obstetrics and Neonatal Care
ENA Essential Nutrition Actions
ENHC Essential Neonatal Health Care
ESOG Ethiopian Society of Obstetrics and Gynecologist
FIGO Federation of International Gynecologists and Obstetricians
FP Family Planning
HBLSS Home Based Live Saving Skills
HEP Health Extension Programme
HEW Health Extension Workers
HF Health Facility
HH House Hold
HIV Human Immunodeficiency Virus
HMIS Health Management Information System
HP Health Post
HSDP Health Sector Development Programme
HSEP Health Service Extension Programme
HTP Harmful Traditional Practice
HW Health Worker
LB Live Birth
LBW Low Birth Weight
IEC Information, Education and Communication
IMNCI Integrated Management of Newborn and Childhood Illnesses
L10K Last 10 Kilometres
IUD Intra-Uterine Device
JSI John Snow Incorporated
MDG Millennium Development Goal
MMR Maternal Mortality Ratio
MNH Maternal and Neonatal Health
III
MPS Making Pregnancy Safer
MVA Manual Vacuum Aspiration
MWA Maternity Waiting Area
NGO Non Governmental Organization
NMR Neonatal Mortality Rate
OF Obstetric Fistula
PAC Postabortion Care
PHC Primary Health Care
PID Pelvic Inflammatory Diseases
PNC Postnatal Care
PNMR Peri Natal Mortality Rate
PPH Post Partum Haemorrhage
RH Reproductive Health
SAC Safe Abortion Care
SBA Skilled Birth Attendance
SNL Saving Newborn Lives
SNNPR Southern Nations Nationalities and Peoples Region
SPE Severe Pre-Eclampsia
STI Sexually Transmitted Infection
TB Tuberculosis
TBA Traditional Birth Attendant
TT Tetanus Toxoid
UN United Nations
VCHW Volunteer Community Health Worker
WRA Women of Reproductive Age
IV
Executive Summary
Although MMR estimates in Ethiopia vary considerably, most agree that the country’s
maternal mortality ratio is among the highest in the world. The Ethiopian Demographic and
Health Surveys of 2000 and 2005 give figures for the period 0-6 years prior to the surveys:
871 and 673/100,000 live births respectively. For neonatal mortality the rates are 48.7/1000
and 39/1000 live births as reported in the EDHS 2000 and 2005 respectively.
The Ethiopian government was one of the first in Africa to make a strong commitment to
the MDGs; reaching each of the MDG targets is central to its national development strategy.
Meeting the MDG 5 target however would mean reducing its MMR by three-quarters to
218/100,000 live births by 2015 from the early 1990’s estimate of 871. A 2008 mid-term
review of the Health Sector Development programme (HSDP-III) found that this is unlikely
to happen given the programme’s present status.
Other major observations of the mid -term review related to maternal and neonatal health,
at the community level, were that there has been limited progress in 1) implementing the
prescribed Reproductive Health (RH) strategy of informational campaigns and mobilization
efforts to discourage early marriage; 2) educating communities regarding danger signs during
pregnancy and child birth; and 3) establishment of community referral mechanisms.
A national scoping exercise was conducted by the Last 10 Kilometers project of John Snow
Inc (JSI/L10k) and the Ethiopian Society for Obstetricians and Gynecologists (ESOG) in close
partnership with the Federal Ministry of Health (FMoH) with funding from the Bill and
Melinda Gates Foundation to learn about community level gaps and efforts; and to identify
priority intervention areas to improve maternal and neonatal health at community level in
Ethiopia. A national workshop of public health professionals, clinicians, researchers, program
managers and policy makers reviewed and discussed the status, barriers and determined
strategic recommendations to advance community level maternal and neonatal health.
The national workshop was organized from May 12 to 14, 2009 under the title of
“Addressing Community Maternal and Neonatal Health in Ethiopia, Evidence-based
Recommendations for Increased Demand, Access to and Use of Services”. The workshop
objectives were:
1. Review maternal and newborn health status in Ethiopia

2. Describe the government program to extend services to home and community,
specifically the HEW and her effort to improve maternal and newborn care
3. Review barriers/facilitators to use of maternal and newborn care services
4. Review on-going or previous maternal/newborn health efforts primarily at community
level
5. Develop an applicable framework to improve maternal /newborn health status
through community-oriented efforts, and
6. Develop evidence- based recommendations.
1|Page
The strategic recommendations developed at the workshop to advance community level
maternal and neonatal health are:
Strategic recommendation 1: Develop capacities for self care, improved care seeking behavior and
birth and emergency preparedness
1. Extend the package for a model family to include essential indicators of maternal and
newborn health
2. Promote use of a trained health worker including a plan for birth attended by a
trained health worker, and early preparations for managing complications by seeking
use of skilled care
3. Promote communication between couples and within the household to support birth
preparedness and implementation
4. Educate mothers and other family members on recognition and proper care of a sick
newborn
5. Include critical MNH issues in the existing community conversation and community
dialogue activities
6. Increase knowledge and develop the skills of women to avoid unwanted pregnancy,
seek safe abortion care services and recognize abortion complications
7. Increase awareness of signs of labor and emergency for mothers and newborns
8. Promote essential newborn care, awareness of danger signs and timely care-seeking
9. Encourage at least 4 antenatal (ANC) visits, labor/delivery and an immediate
postnatal visit (within 24 hours) and a second postnatal visit at 3 days with a trained
health worker; all obstetric and neonate emergencies should go to a trained health
worker.
10. Design, produce and use a birth and emergency preparedness counseling card in
ANC
11. Develop providers’ knowledge and communication skills in birth and emergency
preparedness
Strategic recommendation 2: Increase awareness of the needs and potential problems of women
and newborns during pregnancy, labor and delivery and in the postpartum period
1. Improve couple communication in birth preparedness and joint decision making
2. Improve involvement of men in care of mothers and newborns during pregnancy,
labor and delivery and postpartum
3. Increase individual and social understanding of the needs, risks and dangers of
pregnancy, childbirth and in the postpartum period for the mother and newborn
4. Establish a system for pregnancy and labor/delivery detection
5. Introduce a system of community epidemiological surveillance and maternal and
prenatal death audits
6. Develop capacity of the health system to effectively deliver health education
7. Improve the set up of facilities and providers’ skill on counseling couples
Strategic recommendation 3: Strengthen linkages between the community and the health delivery
system
1. Strengthen collaboration of HEWs with other health providers, community health
workers and traditional birth attendants to ensure the continuity of care and social
support
2. Encourage HEWs to attend deliveries with TBAs and to build support within the
community to alert the HEW of a birth
3. Develop local means of transport for use during emergencies
2|Page
4. Build capacity and facilitate use of community level social networks for accessing
emergency fund
5. Strengthen the capacity of TBAs in recognizing problems early and when necessary
in guiding women to and through the formal health system
6. Establish maternity waiting area in facilities where there is 24/7 CEmONC services
Strategic recommendation 4: Improve access and quality of MNH services

1. Initiate immediate postnatal home visit, within 24hours, a second visit on the third
day, and if possible a third visit on day seven by the HEW
2. Expand outlets for family planning including social marketing of contraceptives
3. Prioritize care during labor and delivery (normal birthing) and neonatal
resuscitation in the guidelines for HEP
4. Ensure proper competency based training of HEWs on safe and clean delivery and
neonatal resuscitation
5. Scale up use of misoprostol by HEWs to manage 3rd stage labor
6. Increase awareness of men and communities of the value of social support during
child birth (Encourage presence of companion during labor and delivery)
7. Build communication and counselling skills of HEWs
8. Organize a standard outreach program with proper schedule
9. Improve method mix of contraceptives including Long Acting and Permanent
Methods
10. Improve the set up of facilities to be client-friendly
11. Advocate for policies that promote social support during labor
12. Encourage presence of at least two birth attendants (one specifically for newborn)
13. Build interpersonal and intercultural competencies of health providers
3|Page
1. Introduction
The maternal mortality ratio in Ethiopia is considered one of the highest in the world, yet
there are few current data. Neonatal mortality rates are also extremely high and only
recently determined at community level. Efforts to improve this situation at the
home/community level where over 90% of the births occur have recently escalated with the
Government’s Health Extension Programme. Given this the Bill and Melinda Gates
Foundation supported a maternal and neonatal scoping exercise to explore the status,
barriers and possibilities to improve the health of mothers and newborns through
community and home level efforts.
This is a report summarizing the preparatory papers, presentations and working group
recommendations for that exercise.
1.1 Background:
Ethiopia is the second most populous country in sub-Saharan Africa with an estimated
population of 74 million in 2009 (CSA, 2008). According to the 2005 EDHS data, the total
fertility rate for Ethiopia is 5.4 births per woman. Over 50% of its population is younger
than 20 years and over 50% of adults are illiterate. Sexual debut occurs on the average at
the age of 20 for males and 16 for females with the median age of marriage for girls in
Ethiopia at 16.1 years. 40% of young women have their first child by 19 years and 54% of
pregnancies to girls under the age of 15 are unwanted.
The government’s health delivery system has adopted a strategy of integrated health
services starting with primary health care and organized into a four-tiered system, consisting
of primary health care units (health centre with 5 satellite health posts); district hospitals;
zonal hospitals; and specialized referral hospital with catchments population of 25,000,
250,000, 1,000,000 and 5,000,000 respectively. Although health care is delivered mainly in
the public sector, the role of the private and NGO sectors is growing.
1.2 Policy Environment:
The policy environment of Ethiopia is rich with plans for improved maternal and child health
dating back nearly two decades. Beginning with the Health Policy of Ethiopia (1993), the
focus was and continues to be on community-based public health preventive and promotive
interventions in the major areas of public health including maternal and child health. The
national policies and strategic documents that relate specifically to maternal and neonatal
health are shown in table 1 along with their component interventions and targets:
4|Page
Table 1: National policies and strategic documents related with MNH
Policy/Strategic documents Components/targets
Making Pregnancy Safer Initiated as the health sector strategy to reduce maternal and newborn
(MPS) initiative (2000) mortality.
Central to the MPS approach is the critical role of skilled birth attendance
and the importance of ensuring a functional continuum of care from the
community to the referral level for effectively reducing maternal and
newborn deaths.
Child Survival Strategy (2005) Identified key interventions for maternal, neonatal and children by mode of
delivery [Interventions: family planning, iron/foliate supplementation,
tetanus toxoid, clean delivery, thermal care and Kangaroo Mother Care
(KMC), exclusive breast feeding, and others]
Identified key interventions by target conditions
Identified main bottle necks for key maternal and neonatal care
interventions [Bottle necks: access to health facilities, shortage of skilled
personnel, lack of essential equipment and supplies, and others]
Listed main activities by intervention and level of care
Reproductive Health Strategy Identified six priorities: the social and cultural determinants of women’s
(2006) RH; Fertility and Family Planning; MNH; HIV/AIDS; RH of young people and
reproductive organ cancers.
The targets related to maternal and neonatal health are:
Increase Contraceptive Prevalence Rate (CPR) to 60% by 2010
Reduce Maternal Mortality Ratio (MMR) to 350/100000 live births by 2015
Reduce proportion of abortion related deaths to 10% by 2015
Reduce Neonatal Mortality Rate (NMR) to 18/1000 live births by 2015
Recommended to develop a national maternal and neonatal mortality
reduction strategy in order to prioritize objectives in safe motherhood and
identify sustainable, high impact interventions required to achieve them.
Adolescent and Youth Further articulated strategies, focus areas and implementation plans with
Reproductive Health Strategy detailed goals for adolescents.
(2006) Goals:
To meet the immediate and long-term RH needs of young people through
increased access and quality of sexual reproductive health services.
To increase awareness and knowledge about adolescent reproductive
health issues.
To strengthen multi-sectoral partnerships and create an enabling positive
environment at all levels.
To design and implement innovative and evidenced based AYRH programs
that are segmented and tailored to meet diverse needs of youth.
Nutrition Strategy (2008) Put promotion of essential nutrition action (ENA) as one of the
components with the following sub components:
Improving the nutritional status of women: education for more intake;
supplement pregnant women with iron/foliate; give pregnant women
antihelmitheics and postpartum vitamin A supplementation
Improving the nutritional status of children: breast feeding and Infant and
child feeding practices
Revised abortion law (2005) Extended the range of indications for safe abortion to include pregnancies
resulting from rape and incest, if it endangers the life of the mother or the
child or the health of the mother, incurable and serious fetus deformity, in
case of physical or mental deficiency and in case of grave and imminent
danger.
5|Page
The third five year program of the Health Sector Development Program, HSDPIII (2005/06
to 2009/10), focuses on poverty-related health conditions, communicable diseases such as
HIV, malaria and diarrhea, and health problems that affect mothers and children with
particular attention to rural areas. The implementation approach of HSDP is framed in four
core strategies: the Health Service Extension Programme (HSEP), the Accelerated
Expansion of Primary Health Care Coverage, a Health Care Financing Strategy and the
Health Sector Human Resource Development Plan. However, it is the Health Service
Extension Programme (HSEP, later shortened to HEP), introduced in 2003, that is seen as
the primary means by which to improve maternal, newborn and child health and address
Millennium Development Goals 4 and 5.
The Health Extension Programme was developed in response to recognition that necessary
basic health services were not reaching people at grass roots level as originally envisioned in
the HSDP. As a sub-component of the HSDP II (2002-2005), the objective of HEP is to
improve equitable access to promotive, preventive and selective curative health
interventions through community or kebele based health services, thereby creating a healthy
environment as well as healthful living. The household is seen as the primary producer of
health and is therefore targeted, particularly women/mothers and children. This approach is
grounded in the principle that the health status of families can be improved with local
technologies and the skill and wisdom of communities.
Through the Health Extension Program, the Ethiopian government plans to extend primary
health care to the rural poor through deployment of about 30,000 government-salaried
health extension workers, two per kebele. Kebele Councils with Woreda Councils recruit
young locally resident women who have completed grade 10 and speak the local language to
become Health Extension Workers (HEWs). Those selected are given one year didactic
and practical training and upon completion of training, are employed by the Woreda Health
Office.
With two HEWs posted at a health post for a population of approximately 5000, they are
to spend 75% of their time for outreach activities, teaching by example through three
approaches-- model families (40-60 families who are early adopters of desirable health
practices), community organizations (e.g., Idir, Ekub, Mahber), and health post and outreach
service delivery (e.g., family planning, antenatal care, immunizations, nutrition counselling,
first aid and referral). Beyond messages, they provide preventive and a few curative services
as detailed in 16 health packages, including five in the Family Health Services component
(e.g., maternal and child health, family planning, immunization, adolescent reproductive
health, and nutrition). The main objective of this component program is to strengthen and
gradually expand family planning and health services for mothers, children and youth,
including nutrition services. Voluntary community health workers support HEW activities
and report to each HEW.
The Ethiopian government was one of the first in Africa to make a strong commitment to
the MDGs and reaching each of the MDG targets is central to its national development
strategy. Meeting the MDG 5 target however would mean reducing its MMR by three-
quarters to 218/100,000 live births by 2015 from the early 1990’s estimate of 871. A 2008
mid-term review of the Health Sector Development programme (HSDP-III) found that this
is unlikely to happen given the programme’s present status.
6|Page
The other major observations of the mid -term review related to maternal and neonatal
health were, that there has been limited progress at the community level, in 1) implementing
the prescribed RH strategy of informational campaigns and mobilization efforts to
discourage early marriage; 2) educating communities regarding danger signs during
pregnancy and child birth; and 3) establishing community referral mechanisms.
1.3 National scoping exercise on the community component of MNH
The community component of maternal and neonatal health programs focuses on the health
of women in reproductive age prior to conception through pregnancy, child birth and the
postpartum period and on newborns from birth through the first 28 days of life with
emphasis on:
 Improving community supports required to improve normal birthing and essential
newborn care plus prevention and treatment of maternal and neonatal
complications/illnesses
 Improving home and community practices by providing better access to health
education, counseling and community based health workers
 Health communication through information, education and communications (IEC).
A national scoping exercise was conducted by The Last Ten Kilometers project of John
Snow Inc (JSI/L10k) and the Ethiopian Society for Obstetricians and Gynecologists (ESOG)
in close partnership with the Federal Ministry of Health (FMoH) with funding from the Bill
and Melinda Gates Foundation to learn about community level gaps and efforts; and to
identify priority intervention areas to improve maternal and neonatal health at community
level in Ethiopia. A national workshop of public health professionals, clinicians, researchers,
program managers and policy makers’ reviewed and discussed the status and barriers to
advancing community level maternal and neonatal health and determined strategic
recommendations to improve this effort.
The workshop was organized from May 12 to 14, 2009 under the title of ‘Addressing
Community Maternal and Neonatal Health in Ethiopia, Evidence-based Recommendations
for Increased Demand, Access to and Use of Services’. The workshop objectives were to:
1. Review maternal and newborn health status in Ethiopia

2. Describe the government program to extend services to home and community, with a
specific focus on the HEW and her efforts on maternal and newborn care
3. Review barriers/facilitators to use of maternal and newborn care services
4. Review on-going or previous maternal/newborn health efforts primarily at community
level
5. Develop an applicable framework to improve maternal /newborn health status through
community-oriented efforts
6. Develop evidence- based recommendations.
The section below summarizes:

a. Presentations made by partners
b. Background papers prepared for the scoping exercise
c. Discussion points from group work and
d. Strategic recommendations developed.
7|Page
2 Maternal and Neonatal Health Status
2.1 Maternal outcomes
Although MMR estimates in Ethiopia vary considerably, most agree that the country’s
maternal mortality ratio is among the highest in the world. In 1980 the estimate was 2,000
per 100,000 live births. Estimates have declined since then to 720 in 2005. The Ethiopian
Demographic and Health Surveys of 2000 and 2005 give similar figures for the period 0-6
years prior to the surveys: 871 and 673/100,000 live births respectively.
Beyond the EDHS, population-based studies are few and none are current. The MMR from
such studies in specific areas range from 566/100,000 live births in a population-based study
in Addis Ababa in 1981-1983, 402 in Jimma town for the period 1986-1990, to 570-725 from
Illubabor in 1991, and from 581 to 665 in Butajira during 1987-1996.
The data from various hospitals in the country (Jimma, Ambo, Adigrat, Tikur Anbessa and
Gandhi hospitals) generally shows a decreasing trend in MMR over the period 1970 to 2009
(Figure 1). As might be expected the MMR for hospitals are higher than national or
community based studies, given that most women who come to facilities are likely to have
complicated deliveries. In the recent Ambo Hospital study for example, it was noted that
26% died in less than one hour of arrival and most women were self-referrals.
Figure 1: Trend of Maternal Mortality Ratio in Hospitals, 1970 to 2009

Trend of Maternal Mortality Ratio in Hospitals
3000
MMR per 100,000 LB
2500
2000
1500
1000
500
0
1970 1975 1980 1985 1990 1995 2000 2005 2010
Years
8|Page
2.1.1 Causes of maternal deaths
As noted from the study of five facilities noted above, the major causes of maternal deaths
in Ethiopia are similar to most developing countries: infection, haemorrhage, obstructed
labor, abortion and hypertension in pregnancy (Figure 2). There are two major changes
noted in the trends for cause of maternal deaths in the last two decades:
 Change in the proportion of deaths ascribed to the different major direct obstetric causes
of maternal deaths
 The appearance of HIV and disappearance of infectious hepatitis as an indirect causes of
maternal death in recent years;
Figure 2: Trend for Major Causes of Direct Maternal Deaths, 1982 to 2008
Trends in Major Causes of direct Maternal Deaths (Hospital Data)

60.0
% of all Maternal Deaths
50.0
40.0
30.0
20.0
10.0
0.0
1982 1983 1991 2001 2003 2008
Years
Abortion sepsis Rubtured uterus & OL
Hemorrhage Eclampsia & SPE
A review of hospital data of maternal death shows the trend of each direct obstetric cause
(see Figure 2) over years (1982 to 2009):
Abortion: Maternal death due to abortion shows a declining trend. In earlier hospital and
community studies, abortion deaths accounted for 20-50% of direct obstetric deaths. In
the analysis of maternal deaths of Tikur Anbessa and Gandhi Memorial Hospitals during
the last two years (2007-8), there were 3 deaths after abortion among 42 reviewed
maternal deaths or 7% of all the maternal deaths. In the same two hospitals, from 1981-
82, there were 37 deaths due to abortion accounting for 26.6% of all the maternal
deaths. In Jimma Hospital, abortion used to account for more than 40% of all the
maternal deaths in 1980s; in the 1990s, the proportion of unsafe abortion deaths
decreased to 26.8%.
Eclampsia: Unlike deaths due to abortion, eclampsia/ preeclampsia related deaths appear
to be increasing proportionately. In the last two years, there were 15 deaths due to
eclampsia/ preeclampsia accounting for 35.7% of the maternal deaths in Tikur Anbessa
9|Page
and Gandhi Memorial Hospitals. In the same two hospitals, in 1981-1983, there were 9
deaths due to eclampsia, 6.5% of the total maternal deaths. The prevalence of eclampsia
(number of women with eclampsia/ total deliveries) in Addis Ababa hospitals does not
show a marked increase-- varying from 1.2% to 7.1% with most studies indicating a
prevalence rate of about 3.3%. On the other hand, the case fatality rate (CFR) within
each hospital of eclampsia generally shows an increasing and worrying trend.
Ruptured uterus: The trend in maternal deaths due to uterine rupture/ obstructed labor
in general appears the same over years. But in some studies ruptured uterus and
obstructed labor cases are classified under haemorrhage and sepsis; obviously there may
be reporting issues. Overall the case fatality rate of ruptured uterus/ obstructed labor
shows an increasing trend in each of the hospitals reporting.
Haemorrhage: Maternal mortality due to haemorrhage lately shows some increment in
two hospital studies in Ambo and in Tikur Anbessa and Gandhi Memorial Hospitals. The
reason for the high proportion of maternal deaths following haemorrhage at Ambo
hospital (34%) might be due to listing maternal deaths with uterine rupture as
hemorrhagic deaths.
Infection: Overall there appears to be a slight decline in hospital maternal deaths due to
sepsis. But, when the underlying complications are reviewed in all maternal deaths,
infection complications are noted in most of the maternal deaths. For example, among
24 maternal deaths in the last two years at Tikur Anbessa, 12 (50%) of them had
infection complications from pneumonia, PID, HIV, or TB.
Hepatitis: Earlier community and hospital studies of the 1980s in Addis Ababa indicate
that infectious hepatitis was a common indirect cause of maternal death accounting for
13-15% of all the maternal deaths. No recent study implicates hepatitis as a cause of
maternal deaths.
HIV: HIV appears in some recent hospital and community studies to account for 3-4% of
all maternal deaths. Underreporting is likely as most women’s HIV status is unknown.
Malaria: Jimma and Tigray studies indicate that malaria accounts for up to 23.3% of
maternal deaths. Malaria might be an important cause of maternal deaths in endemic
areas.
Detailed data available from Attat hospital, 1987-2008, shows a decreasing trend in maternal
deaths (over 2000 in 1987 to less than 200 per 100,000 live births in 2008). The major
causes of maternal deaths (193) in the years 1987 to 2008 were: ruptured uterus (31%),
sepsis (18%), PPH (10%), eclampsia (8%), anemia (8%), malaria (7%) and abortion (4%).
From the recent national EmONC baseline assessment, 2008/9, from 806 facilities,
preliminary results show that:
Of all obstetric complications treated in the facilities, direct causes accounted for 85%
while indirect causes accounted for 15% of the complication.
Of direct obstetric complications; obstructed/prolonged labor accounted for 37%
followed by retained placenta (22%), severe pre-eclampsia/eclampsia (8%) and severe
abortion complication (8%).
Of indirect obstetric complications; HIV/AIDS related illness accounted for 66%,
followed by anemia (14%) and malaria (13%).
10 | P a g e
Of the total (553) maternal deaths in the facilities, 74% are caused by direct while 26%
are caused by indirect obstetric complication. (Note that these facility deaths are a small
fraction of the estimated 19,000 maternal deaths nationwide each year)
The major causes of facility-based maternal deaths were: obstructed/prolonged labor
(17%), ruptured uterus (15%), severe pre-eclampsia/eclampsia (14%), malaria (12%),
postpartum hemorrhage (9%) and severe abortion complications (7%).
2.1.2 Fistula—another major outcome of pregnancy
Of the approximately two million women who suffer from obstetric fistula (OF) worldwide,
an estimated 27,000 or 14% live in Ethiopia. Based on a prevalence study in seven of the
eleven administrative regions that found a rate of 2.2 OF/ 1000 women of reproductive age
and 1.5 untreated OF per 1000, women with OF were young, had married early in life
through family arrangements or abduction, and had delivered for the first time. Over 95% of
fistulas are caused by obstetric complications according to studies in Ethiopia, specifically
prolonged obstructed labor. Days in labor ranged from three to eight in one Fistula
Hospital study, one to six days in another with a mean of 3.9 days, and from one to nine
days with a mean of 4 days in yet another study. In another study distance, financial
constraints and poor knowledge of prolonged labor were cited for delays in decision making
and transport to facility during labor.
The consequences of fistula in Ethiopia are multiple and devastating: 93% had a stillbirth,
97% of the women had mental health dysfunction, 68% had no living children, nearly 54%
were divorced, 13% were not allowed to eat with family members and 41% did not belong
to any community association. Among those who became depressed, 54% had suicidal
ideation. Many of these issues are not resolved by fistula treatment/repair alone: 3 of 7
treated women in a cross sectional study for example still experienced suicidal ideation; in
another Fistula Hospital study over half of treated women still reported persistent urinary
incontinence and 38% reported altered fecal continence at follow up. Uncounted other
fistula sufferers cannot even access treatment/repair services as the travel to services may
be extreme: patients studied in the Addis Ababa Fistula Hospital case series reported having
travelled 700 km or more, or walking more than 12 hours on average, in order to reach the
hospital for treatment.
2.1.3 Service coverage to ensure maternal health
The service coverage results from the national 2008/9 EmONC baseline assessment
showed:
The national coverage for basic and comprehensive EmONC facilities is only 11% of the
standard set in the UN process indicators (5 facilities per 500,000 populations); it ranges
from 2% to 109% among the 11 regions of Ethiopia. Of the surveyed hospitals 14% are
basic and 50% are comprehensive while only 1% of the surveyed health centers provides
basic EmONC.
Institutional delivery is only 7%, ranging from 2% to 63% among regions. 57% of the
institutional deliveries are at hospital level. This figure remains almost the same since the
2000 DHS.
Met need (defined as the percent of deliveries with complications divided by the 15% of
all live births expected to be complicated) is only 6%, with a range from 0.4% to 49%
among regions
The caesarean section rate at national level is 0.6% with a range from 0 to 9.9% among
regions.
11 | P a g e
There was virtually no progress between 2000 and 2005 in use of antenatal care (ANC)
provided by a health professional—the proportion of women who had at least one ANC
consultation was 27% in 2000 and 28% in 2005. The proportion of pregnant mothers that
received iron supplementation and antihelmithic, according to the 2005 DHS, was 10% and
4% respectively. The studies in 2008/2009 by JSI/L10K project and Save/SNL showed slight
improvement in iron supplementation, 15-17%, and deworming during pregnancy (14%).
The role of antenatal care in reducing maternal mortality has been controversial. However
the experience of Attat hospital showed that high risk women who use a maternity waiting
area (MWA) have decreased maternal deaths and complications as well as lower rates of
still births and low birth weight babies. A higher rate of caesarean section is observed for
those mothers from MWA than non-MWA.
The use of postpartum care with a skilled care provider among women outside of
professional birthing care remains very limited-- 5.5% using such care during 2001- 2005, 5%
within the first 48 hours after birth (EDHS).
Increased coverage in the use of modern contraceptives by women of reproductive age in

the past four years has been shown in a large scale survey in four of the most populated
regions: Tigray, Amhara, Oromia and SNNP. The 2008/2009 survey results showed
increased use of contraceptives from 15.4% of 2005 EDHS to 31.5% for the same
geographic locations. The same survey showed an increase in the use of injectable
contraceptives-- from 11.2% to 27.2% and a decrease in use of other methods; the use of
pills decreased from 3.6% to 2.6 and Norplant/IUD from 3% to 1.5%.
2.2 Neonatal outcomes
The 2000 Ethiopian DHS reported a neonatal mortality rate of 48.7/1000 live births whereas
the rates of the two five year periods preceding that survey were 68.3 and 63.4 /1000 live
births respectively. The rate declined by 29% over the last fifteen years preceding the 2000
survey and 23% over the previous 10 years period (1990-1999). Five years later, the EDHS
2005 showed a neonatal mortality rate of 39/1000 live births (18% decline over the 2000
EHDS rate). The rates in the two consecutive five years periods prior to the survey were 42
and 46 per 1000 live births Like EDHS 2000, the rates in 2005 show a 11% decline in
neonatal mortality in the last 15 years preceding the survey.
The stillbirth and early neonatal death rates from the EDHS 2005 were 10.4 and 26.9 per
1000 total births respectively, giving an overall perinatal mortality of 37 per 1000 total
births. In the EDHS 2000, stillbirth and early neonatal death rates were 18.7 and 33.7 per
1000 total births respectively, making an overall perinatal mortality of 52.4 /1000 total
births. Comparing the rates from the two surveys (2005 with the 2000 EDHS), the PNMR
has seen a 29% decline from 52/1000 to 37/1000. In both the EDHS of 2000 and 2005
neonatal mortality data show that the proportion of infant deaths occurring in neonatal
period is the same-- 50% of infant deaths in the country occur in the neonatal period of life.
Figure 3: Mortality rates for Neonatal and Perinatal periods
12 | P a g e
Mortalityy rates forr Neonatal and Perin
natal
periods, EDH HS, 2000 and 2005
60.00
0
50.00
0
40.00
0
30.00
0 EDHS 200
00
EDHS 2005
5
20.00
0
10.00
0
0.00
0
Still birth
h Early Perinatal Neonaatal Po
ost
neonatal mortallity mortaality neon
natal
deathss morttality
Commun nity based data

d from So outhern cenntral Ethiopiaa, in the disstrict of Meeskan-Mareko o,
Gurage zone,
z from a continuouss demographhic surveillannce system mmaintained by b the Butajirra
rural heaalth program
m for the lastt two decadees, followed a total of 15,667 birthss for a total of
o
426,739 person-dayss during the 10 year perriod (1987-1996). Early (0-6 days) and late (7-277)
neonatal deaths were found to be b 305 (19.55 per 1000 liive births) and 121 (7.7 per 1000 livve
births) reespectively making an overall
o neonnatal mortality rate (NM MR) of 27 perp 1000 livve
births (955%CI: 24.5, 29.5).
Another community based studyy with1878 d deliveries in rural Amhaara region, Ebinat
E districct,
South Go ondar zone, revealed an n overall perrinatal morttality rate off 39 per 10000 total birthhs
with a sttill birth ratee and early neonatal mo ortality ratess of 22 and 17 per 10000 total birthhs
respectivvely for the years 20066/2007. Thee neonatal mortality
m ratte was 19 per
p 1000 livve
births, similar to thhe early neeonatal morrtality, show wing that almost all neeonatal deatth
occurredd during the first seven days
d of life.
The few institution-bbased perinaatal mortalitty studies arre from teacching hospitaals. Note thaat
“perinataal” in these institutional studies refers only to thhose babies while motheers/babies arre
in the hoospital; hencce the perinaatal rates arre likely an underreportting of the true
t rate thaat
includes all stillbirth
hs and deathhs to babies through the t first sevven days of life althouggh
women whow deliverr in facilitiess are likely to have woorse outcom mes as theyy are typically
complicaated deliveriees. A four-yyear retrospective analysis (1985-19989) of 42511 deliveries in
Jimma ho ospital, South-western Ethiopia,
E reported a periinatal mortality rate of 95.9
9 per 10000
births. Another
A retroospective peerinatal morrtality audit (n=
( 13,425 births)
b in thee consecutivve
13 | P a g e
ten years (1990-1999), in the same hospital, revealed an overall perinatal mortality rate of
138.9 per thousand total births with annual distribution of PNMR from 75.7/1000 total
births in 1991 to 213.3 per thousand total births in 1995. The author generally attributed
the inflation of perinatal death to self-referral of high-risk mothers with high probability of
bad outcomes to the hospital. The absence of consistent obstetric record system in the
hospital at different times could also explain the wide difference across the years.
A retrospective data analysis of perinatal deaths occurring in the Black Lion teaching hospital
in 1980 showed a perinatal mortality rate of 52.6/1000 total births. Another five years
(1981-1985) retrospective data from 18,675 deliveries in the same teaching hospital
revealed a perinatal mortality rate that ranges from 65.5 per 1000 in 1985 to 102.5/1000
total births.
The national EmONC facility baseline assessment in 2008/2009 indicated a perinatal

mortality rate of 45/1000 total deliveries.
Figure 4: Causes of neonatal deaths
Estimated direct causes of neonatal death for

Ethiopia for the year 2004
• Causes of neonatal deaths

Othe r
Conge nital 7%
Infections 4%
As phyixa
account Diarrhoe a
25%
3%
for 47% of
neonatal Te tanus
deaths in 7%
Ethiopia
Infe ction
37% Prete rm
17%
CHERG-2004
The most common causes of neonatal deaths in Ethiopia are related to infection as shown in
Figure 4.
2.2.1 Service coverage to ensure neonatal health
The EDHS of 2005 reported that last births were protected against neonatal tetanus for
28% of pregnant women, with younger women and those with lower order births (3 and
below) slightly more likely to have protection compared with their older or higher order
counterparts; those who were the richest and most educated also showed an advantage in
level of protection. The 2008/2009 community based surveys by Save/SNL and JSI/L10K
projects showed increased coverage to 37% and 56% respectively.
14 | P a g e
3. Home Practices and Care Seeking in MNH
In the EDHS 2005, 81% of women stated that they did not seek medical care for birth
because of their concern that there would be no provider. About 7 of every 10 women
stated that money required for treatment, no female health provider, lack of transport, and
no one to complete household chores were major issues for them. For 6 of every 10
women distance to a health facility and not wanting to go alone were perceived as
problems. A third perceived permission to go for treatment as problematic.
The evaluation of the Making Pregnancy Safer project found that total hospital deliveries at
four MPS sites increased over the period of 2001 to 2005, but that poor provider attitude,
including harassment, lack of attention to women’s complaints, and lack of follow up in
labor, were deterrents to use of delivery services. Other critical barriers included: cost,
distance, lack of community support mechanisms, loneliness (no companion during labor),
traditional belief, lack of awareness of benefits of facility delivery, fear of operation or
stitching, fear of referral, and families’ preference for home delivery.
Barriers may vary by region, study methodology or interpretation of data. In one rural study
in Butajira, south central Ethiopia, which used both qualitative and quantitative means, the
decision to seek care for any woman’s health problem was found to be highly dependent on
the husband’s decision (89.3%), and facility care would only be sought after traditional means
of help in the woman’s immediate area had been exhausted. Younger women in particular
were less independent in making decisions regarding visiting a health care centre than older
women.
The national Safe Motherhood Community-based Survey (2006), a qualitative study, also
found that gender-dynamics governed decision-making and resources with regard to care
seeking, with community the first and primary site of care. Ownership of the community
over childbirth was considered very important; the authors stated that “the decision over
where to give birth is a balance between securing a safe delivery and retaining control and
ownership over the process.” This desire for community control also influences the timing
of referrals and plays into the attribution to evil spirits for poor outcomes in the community
rather than to local traditional providers. Type of complication may also influence the type
of care sought: bleeding, especially in primiparous women, is seen as normal; prolonged
labor may be caused by activity during pregnancy and treated with herbal or spiritual-based
interventions.
In contrast to delivery which is seen as the highest risk period, pregnancy is perceived as
low risk for the mother and more focused on the fetus, and hence use of antenatal care
remains low (28% according the EDHS 2005). Tetanus toxoid injections during pregnancy
are an exception (although still only received by a third of women), and are sought for their
perceived benefit to the baby and to insure against prolonged or complicated delivery.
With the exception of the immediate post-delivery period when bleeding and retained
placenta are linked with the high-risk delivery, the remainder of the postpartum period is
viewed also as low risk for mothers but high risk for newborns, especially from malevolent
spirits. To guard both, the 40 day rule for home confinement is commonly observed,
virtually ensuring low use of any outside care.
15 | P a g e
Studies have noted that women perceive health providers as insensitive and unduly harsh
specifically if they come late for care, or their clothing is dirty; the providers are also felt to
be unresponsive to community beliefs and practices. Delivery procedures in particular are
perceived as alien and unnatural, and act as a significant deterrent to facility births. Referral
may be seen as a measure of incompetence and only exacerbates existing suspicion of
incompetence and inefficiency of both health facilities and providers.
The Safe Motherhood Initiative of ESOG, a project with collaboration of FIGO and the
Oromia Regional Health Bureau, explored factors that account for under utilization of
EmOC services by women living in three woredas of West Shoa zone in 2002. The key
factors found most closely linked with health seeking of women in this community were lack
of education, low income, traditions, not knowing availability of delivery services, distance
from health institutions, poor infrastructure (like road and transportation) and institutional
related factors. Other factors contributing to underutilization of services were negative
traditional attitude and practices, fear and misconceptions about institutional delivery and
negative health provider’s attitude towards clients. The community level self help
organizations, Golebe and Idir, where they exist, were found to have strong influence on
promoting institutional delivery by making loans available and organizing people to carry the
women.
A study conducted in 2006 by Ipas Ethiopia to explore reasons for low utilization of
postabortion care (PAC) services in six districts of Amhara, Oromia and SNNPR indicated:
Limited knowledge of timing of when pregnancy could occur during the menstrual
cycle and after occurrence of abortion
Limited knowledge of the consequences of unsafe abortion and warning signs and
symptoms of abortion complications and the need for visiting health facilities, along
with availability of services
Only 28% of the respondents know the legal indications for safe termination of
pregnancy
Negative attitude of community members for sexual intercourse and pregnancy
before marriage
Stigma and discrimination of women faced with abortion
The main reason for not visiting any facility for comprehensive abortion care (postabortion
and safe abortion care services) services is lack of family-community support.
Unmet need for contraceptives can translate into use of unsafe abortion and maternal death.
The 2008/9 study by JSI/L10k project in Oromia, Tigray, Amhara and SNNP regions
indicated that the reasons for not intending to use FP in the future are: fertility related
reasons (36%); opposition to use (27%); method related reasons (15%) and lack of
knowledge (7%).
Immediate newborn care practices of mothers with children 0-6 months determined by the
baseline household census of Save the Children /Saving Newborn Lives in East Shoa, West
Arsi and Sidama zones of Oromia and SNNP regions in 2008/9, included the following:
Newborns are dried and wrapped before the placenta is delivered in 51% of
deliveries
54% of newborns placed alone, separate from the mother immediately post-delivery
The proportion of newborns bathed after 24 hours is 20%
94% use new razor to cut the cord
16 | P a g e
No substance is applied to the cord in 82% of newborns
29% initiated breast feeding within 1 hour after delivery
36% of mothers did not discard colostrums
7% of newborns had reported illness during first month. 41% sought care for illness--
25% from hospitals, 5% from health centers and 12% from health posts.
4. Efforts/Experience to Improve MNH at Community/Home Levels

4.1 Health extension worker level
A 2006 study of 60 HEWs from the first batch of HEWs posted at least 6 months in six
regions [Amhara, Benshangual and Gumuz, Harari, Oromia, SNNPR and Tigray] of the
country, found that staffing was variable with many areas opting to place one HEW per
Health Post until they received their full complement. Work accomplished focused primarily
on health education and some on environmental health. Family health services, including
deliveries, were virtually not implemented; 40% had made referrals but did not have
feedback on the patients. In some places (eg., Oromia, Harari, Benshangual and Gumuz) a
nurse or other health worker accompanied the HEW and covered the family health
functions. Relations with the kebele administration and with community workers (e.g.,
CHWs, CHAs, and CBRHAs) were not clear. Few HEWs had carried out the community
surveys originally planned as the basis for a community level plan of work. From the
community perspective, the most pervasive need was for curative care which was not the
primary function of the HEW.
In another 2006 community-based study of perceptions of HEP a year after implementation,

58% of 60 female heads-of-household randomly selected in a very remote area of Tigray,
said their HEW was very helpful and 93% said they preferred an HEW over a Traditional
Birth Attendant to assist them during labor because a HEW seemed more knowledgeable
and accessible. Other findings suggested limited HEW households visits (85% received
monthly or less frequent visits), and topics covered (only 13% reported use of
contraception was discussed).
Two years later, reviewers at mid-term of HSDP III (mid- 2008) were encouraged by the
HEP, noting that maximum output was achieved at the half way mark in the program and
that the major HSDP objective of universal PHC coverage with HEP by 2007/8 was very
likely to be achieved with some exceptions. The review noted that HEP had created a firm
and comprehensive health service base to accessing health services at the community level
for the first time, increasing the potential health service coverage above 90% in most parts
of Ethiopia.
However, with specific focus on maternal health the reviewers stated: “In maternal health,
there is need to limit the scope of functions that is expected of the HEWs.” They stated
that HEWs are not expected to be involved in delivery care at the moment, and suggested
that the HEW should concentrate in supporting TBAs with utilities and training to improve
their delivery skills and care. Contrary to the earlier studies, they found that the community
does not view the young HEWs as seriously as the older TBAs regarding delivery care.
Other constraints noted essentially confirmed earlier study findings concerning inadequacies
of HEW training, health post infrastructure and supplies.
17 | P a g e
The physical targets set for HEP have been reached or are close to being reached according
to recent government reports. The Federal Ministry of Health reported in May 2009 that
30,193 HEWs are deployed (exceeding the 30,000 target) and nearly 11,000 of the required
15,000 health posts are constructed (73%).
An independent sample survey (2008/9) of the JSI/L10K project in four regions (Tigray,
Amhara, Oromiya, and SNNP), by the end of 2008, found that:
92% of kebeles have at least one HEW
About one-fifth of the HEWs had received a 4 week in-service training (post their
one year basic training) that included information on safe and clean delivery and a
quarter had received training in essential neonatal health care (ENHC)
Even so, little work time was used on these services according to the HEWs—a
median 2 hours per week for delivery services, 1 hour for ENHC, 4 hours for ANC
and 3 hours for PNC. The majority of their time was spent on environmental
education and immunization.
Over 50% of the health posts had the delivery couch and delivery kits on hand but
supplies for maternal health services, such as iron tablets, ergometrine and
misoprostol were less available (33%, 7% and 5% respectively).
Over 50% of mothers with 0 -11 month old children visited the health post. The
visits were mainly for immunization activities. The visit for ANC, deliveries and PNC
were reported at 37%, 1.3%, and 5% respectively.
The home visit by HEWs for pregnancy check up was reported in 12% of mothers
with children 0-11 months.
Only 4% of deliveries were attended by HEWs
Of women of reproductive age interviewed, 19% had heard of model families and
10% are living in a HH graduated as a model family. 18% of interviewed women in
reproductive age want to be a model family
HEWs visit improved ANC, delivery, and PNC coverage.
Being a model family influenced use of ANC, tetanus immunization, delivery and
PNC.
Five HEWs, one each from Afar, Tigray, Amhara, Oromia and SNNP who were
selected by the respective Regional Health Bureau as an outstanding HEW,
participated and presented their activities at the workshop. Of the women with
expected pregnancies in the catchment areas of the five health posts of these HEWs,
over 50% attended ANC and 37% received TT2. Similarly, of the expected deliveries,
only 6% were attended by HEWs and 24% received PNC. A summary of the
presentations of these HEWs is shown in the following table (2).
18 | P a g e
Table 2: Catchment population and nine month performance report of HEWs (5) by region
Afar Tigray Amhara Oromia SNNPR
Catchment population 10662 8900 5869 5006 4930
Number of households 2800 1438 850 881 1049
Number of expected pregnancies 533 445 293 250 247
Nine Months (July 2008 – March
2009) report
Number of health post attendees 585 2052 169 1088 1979
Number of ANC attendees _ 1st visit 53 180 88 88 107
_ 2+ visit 144 324 224 98 141
Tetanus toxoid _ TT1 184 15 14 0 23
_ TT2 160 173 78 145 91
Delivery by _ TBAs 119 30 45 No report 118
_ HEWs 0 45 36 11 12
Number of PNC attendance 80 75 83 59 130
4.2 Community level
Home Based Life Saving Skills (HBLSS) is a multi-pronged approach including both family
focused training and community mobilization programs to improve problem recognition and
first aid response to maternal and newborn complications and increase timely access to
EmONC. A pilot project in Liben woreda, Guji zone of Oromia region showed the
following:
Improved knowledge and case management of home births
Acceptable to families and communities
Demonstrated learning transfer and skills uptake by birth attendants
Demonstrated improved referral
Compatible with HEP strategy – through HEW, VCHW, other community level care
givers.
The experience of ESOG community level interventions in the use of birth preparedness
and complication readiness (BPCR) plan counseling cards showed increased demand by
health providers and pregnant women that could indicate acceptability and need for better
care. The team concluded that the wide scale introduction of BPCR practice as a strategy to
increase demand for institutional birth maximize coverage of key intervention like AMTSL.
An introductory trial of misoprostol using HEWs for community level prevention of PPH
showed misoprostol can be safely and effectively administered by HEWs if preceded by
proper training and supervision. Another study of prevention of PPH at home births with
TBAs in Tigray region also showed that TBAs can safely and easily administered
misoprostol. Women who took misoprostol were 58% less likely to be referred for
additional intervention to the health facility because of excessive bleeding.
4.3 Facility level
The 1999 FIGO Save the Mothers Project (a joint effort of the Ethiopian Society of
Obstetricians and Gynecologists and the Swedish Society of Obstetrics and Gynecology)
initiated its work in West Showa Zone with a needs assessment with the objective of
reducing maternal deaths by promoting availability, access and use of EmOC services for
women with complications of pregnancy and childbirth. The intervention package included
19 | P a g e
training physicians and other service providers and provision of equipment, materials and
supplies. Despite improvements in coverage resulting from the project (for example total
number of patients treated in Ambo hospital for obstetric complications rose from 128 in
1998 to 432 in 2001 and the number of caesarean deliveries rose from 27 to 171 in that
same time period), the authors noted, “WSZ [West Showa Zone] does not meet minimum
criteria for obstetric coverage set by the UN; the zone therefore needs an additional four
hospitals and 18 health centers to be built to provide services for treating obstetric
complications.”
In 2000 the FEMME project of CARE aimed to create functional health facilities with trained
and competent staff in an enabling environment supporting EmOC service delivery over a 4-
year period starting with improvements at facility and district level in Oromiya region. Of
the three African countries CARE worked in (Ethiopia, Tanzania, Rwanda), Ethiopia was
considered the most challenging because of the significant renovation needed in target
hospitals, the inconsistency of available blood for transfusion, and staffing shortages and
turnovers among midwives and health assistants in the labor ward. After four years,
progress was made in all indicators — proportion of births in EmOC facilities went up from
1.6% to 2%, met need for EmOC services increased from 2 to 4.5%, caesarean section rate
increased from 0.2% to 0.4% and case fatality rate reduced from 10.4% to 5.2%—but all
remained at significantly lower levels (higher in the case of CFR) than in Rwanda and
Tanzania. The authors felt these findings reflected the greater challenges (distance and
transport, scarce resources, poor management and accountability in health care and broad
inadequacies in the health system) and constraints in accessing health services in the country
as a whole.
The Making Pregnancy Safer Initiative, a project of the Federal Ministry of Health with UN
organizations, the European Commission and Swedish SIDA, aimed also to increase
availability of EmOC in four pilot regions, initiating work in 2001 in four hospitals and 16
health centers. Like the others, the MPS project provided training on basic and
comprehensive EmOC, and found that five years later, the trained staff had improved over
untrained staff in practical test scores (both knowledge and skills) for infection prevention,
newborn resuscitation, vacuum extraction, manual removal of the placenta, partograph,
manual vacuum aspirator and AMTSL, but not significantly. Process indicators of numbers
of deliveries and caesarean sections had increased, but unreliable supplies of blood, oxygen,
supplies for infection prevention, and even water, along with the prevailing scarcity of health
care providers and program managers continued to hamper performance.
Addressing human resource gaps to increase EmOC services through provision of needed
obstetric and surgical skills to non-specialists builds on previous pilots. One such pilot took
place in Tigray between 2004-7 resulting in the successful nine month training of 24
CEmONC teams and upgraded district hospitals and health centers. The evaluation noted
enumerable challenges to this effort, starting with the lack of adequate trainers and the
caseload needed for practical training. Blood is primarily from family donations and there
were frequent stock outs of transfusion supplies—and the challenges go on. The curriculum
was heavily biased towards obstetric surgery; more time for basic obstetric care was
needed as well as management of normal labor and delivery. The evaluation in 2007 found
only 36% of the teams trained in EmOC providing such care post-training. This gap between
training and service provision was due to issues of facility preparation at the sites where the
teams were posted after training—insufficient equipment and infrastructure (e.g., water,
electricity, delivery kits), as well as inadequate management and monitoring.
20 | P a g e
The assessment reports of Ipas Ethiopia, covering over 300 public facilities, in Tigray,
Amhara, Oromia and SNNPR regions indicated an improvement in the capacity of health
facilities to manage abortion complications: improved availability of MVAs, trained provider
and uterine evacuation services; and improved quality of Postabortion Care (PAC) services
(use of MVA, pain medication and Pstabortion family planning). The proportion of facilities
providing safe abortion care (SAC) services and cases visiting facilities for SAC services
increased in the last 2-3 years.
The national EmONC baseline assessment, 2007-2008, also showed that use of specific
evidence-based interventions is low: use of parental antibiotics for newborn is 24%;
provision of extra care to premature or low birth weight (LBW) is 24% and only 2% of
facilities provided magnesium sulphate.
5. Group Work: Conclusions and Recommendations

Workshop participants formed six groups around the periods of maternity and newborn
care: pre-pregnancy, pregnancy, labor and delivery (one for mother and one for newborn)
and the postpartum period (one for mother and one for newborn). Each group was
provided with lists of internationally recommended interventions and requested to select
priority intervention for Ethiopia. The groups discussed the status and barriers of
implementing those selected interventions at Health Extension and Community/Outreach
levels and issues related to referral linkage. A simple frame work was provided to complete
group work.
The result of the group work/discussion is presented in full in the following two tables
(3&4): the first table (3) lists the priority interventions, status, barriers and conclusions
discussed from each group; and the second table (4) is the strategic recommendations with
priority interventions by level of care pooled from the whole group work and discussion.
Generally the strategic recommendations fall into four categories to advance community
level maternal and neonatal health. They include the following:
Strategic recommendation 1: Develop capacities for self care, improved care seeking behaviour and
birth and emergency preparedness
1. Extend the package for a model family to include essential indicators of maternal and
newborn health
2. Promote use of a trained health worker including a plan for birth attended by a trained
health worker, and early preparations for managing complications by seeking use of
skilled care
3. Promote communication between couples and within the household to support birth
preparedness and implementation
4. Educate mothers and other family members on recognition and proper care of a sick
newborn
5. Include critical MNH issues in the existing community conversation and community
dialogue activities
6. Increase knowledge and develop the skills of women to avoid unwanted pregnancy, seek
safe abortion care services and recognize abortion complications
7. Increase awareness of signs of labor and emergency for mothers and newborns
8. Promote essential newborn care, awareness of danger signs and timely care-seeking
9. Encourage at least 4 antenatal (ANC) visits, labor/delivery and an immediate postnatal
visit (within 24 hours) and a second postnatal visit at 3 days with a trained health
worker; all obstetric and neonate emergencies should go to a trained health worker.
21 | P a g e
10. Design, produce and use a birth and emergency preparedness counseling card in ANC
11. Develop providers’ knowledge and communication skills in birth and emergency
preparedness
Strategic recommendation 2: Increase awareness of the needs and potential problems of women
and newborns during pregnancy, labor and delivery and in the postpartum period
1. Improve couple communication in birth preparedness and joint decision making
2. Improve involvement of men in care of mothers and newborns during pregnancy,
labor and delivery and postpartum
3. Increase individual and social understanding of the needs, risks and dangers of pregnancy,
childbirth and in the postpartum period for the mother and newborn
4. Establish a system for pregnancy and labor/delivery detection
5. Introduce a system of community epidemiological surveillance and maternal and
perinatal death audits
6. Develop capacity of the health system to effectively deliver health education
7. Improve the set up of facilities and providers’ skill on counseling couples
Strategic recommendation 3: Strengthen linkages between the community and the health delivery
system
1. Strengthen collaboration of HEWs with other health providers, community health
workers and traditional birth attendants to ensure the continuity of care and social
support
2. Encourage HEWs to attend deliveries with TBAs and to build support within the
community to alert the HEW of a birth
3. Develop local means of transport for use during emergencies
4. Build capacity and facilitate use of community level social networks for accessing
emergency fund
5. Strengthen the capacity of TBAs in recognizing problems early and when necessary in
guiding women to and through the formal health system
6. Establish maternity waiting area in facilities where there is 24/7 CEmONC services
Strategic recommendation 4: Improve access and quality of MNH services
1. Initiate immediate postnatal home visit, within 24hours, a second visit on the third day,
and if possible a third visit on day seven by the HEW
2. Expand outlets for family planning including social marketing of contraceptives
3. Prioritize care during labor and delivery (normal birthing) and neonatal resuscitation in
the guidelines for HEP
4. Ensure proper competency based training of HEWs on safe and clean delivery and
neonatal resuscitation
5. Scale up use of misoprostol by HEWs to manage 3rd stage labor
6. Increase awareness of men and communities of the value of social support during child
birth (Encourage presence of companion during labor and delivery)
7. Build communication and counselling skills of HEWs
8. Organize a standard outreach program with proper schedule
9. Improve method mix of contraceptives including Long Acting and Permanent Methods
10. Improve the set up of facilities to be client-friendly
11. Advocate for policies that promote social support during labor
12. Encourage presence of at least two birth attendants (one specifically for newborn)
13. Build interpersonal and intercultural competencies of health providers
22 | P a g e
Table 3: Priority interventions: status and barriers of implementation
Priority Status of Implementation Barriers of Implementation Conclusion
Interventions
Pre-pregnancy
√ Family planning Ω High unmet need for family ∞ Need for larger family → Problem based education strategy; use traditional media
√ Counselling, planning ∞ Limited male involvement to disseminate information; reach women in culturally
testing, Ω Limited STI/HIV services at ∞ Gender inequality/power relationship, male sensitive way
prevention and community level dominance. Decisions are made mainly by males → Inform and involve opinion leaders and elders
treatment Ω Law of age at marriage is ∞ Limited communication at household level about → Improve enrolment and minimize drop out of girls from
services for STI not known by most sexual related issues school
and HIV community members, not ∞ Misconception, gossips and rumours about FP → School based intervention with information, counselling
√ Nutrition enacted ∞ Conflicts with community norms/traditional law and services
counselling for Ω Improved enrolment of ∞ Limited access to media → Reaching out of school adolescents through house to
prevention of girls in school ∞ Strategies for communication are not based on house visit
malnutrition and Ω Long-term/permanent BCC → Counselling and information sharing about where/how to
anaemia contraceptive services are not ∞ Lack of coordination among different sectors obtain contraceptives
√ Delay marriage/ available at health post level ∞ Lack of method mix of contraceptives → Improve method mix of family planning
childbirth to Ω Most of RH services are ∞ Clients have to travel to a health centre or → Improve counselling skill of HEWs
age 18 provided free of charge in the hospital to get long-term/permanent contraceptive → Outreach program, using market days for education and
public facilities methods and have to wait for long hours provision of contraceptives
Ω Few NGOs worked on ∞ Influence on choice of methods by providers, → Pre- arranged schedule for referral to facilities; type of
revolving scheme to avail providers bias procedures and number of clients
contraceptive methods ∞ No adolescent friendly service → Social marketing of contraceptive methods
Ω Limited effort in prevention ∞ Inappropriate set up of facilities. Facilities are → Improve service quality; train staff on informed choice,
of malnutrition and anaemia not client friendly ensure privacy and confidentiality
∞ Poor management of health facilities; lack of → Improve set up of facilities to be client friendly
accountability and staff motivation → Improve/strengthen health facility management
Pregnancy
√ Birth and Ω Service existed as part of ∞ No BCC tool; lack of message clarity; message → Capacity building of HEW through on job, in-service,
emergency focused ANC provision, most did not involve partner, family and community training
planning: advice issues addressed ∞ Pregnant women are not prioritized as a group → Develop BCC tool; standardized and harmonize messages
on danger signs Ω Limited knowledge of for timely counselling and visits by the HEWs → Implement community conversation and mobilization
and emergency HEWs ∞ No outlaid process for community conversation model for maternal and neonatal health
preparedness or community mobilization, how it works → Improve the emphasis on community mobilization and
23 | P a g e
Ω No program of community ∞ Limited awareness of policy makers IEC/BCC for birth preparedness and use of referral
conversation or community ∞ Lack of involvement of male, mothers in laws → Couple communication and shared decision making for
mobilization focusing on and other family members in birth preparedness birth planning
maternal health ∞ Low financial capacity of women/ community → Improve role of male and other influential’s, through male
Ω No scheduled outreach ∞ Problem of finance and means of transportation group
program for ANC at kebele ∞ Low knowledge of health care providers on → Involve men on birth preparedness and emergency
level BPCR readiness, preventing early marriage, early pregnancy, and
Ω Transport and its cost is ∞ Low knowledge and practice of focused ANC helping women at the time of labor and delivery
unaffordable → Extend role of model family to include birth and
emergency planning
→ Advocacy at CBO and Kebele council level, to increase
awareness
→ Establish system for pregnancy identification (HEW-
VCHW-health committees)
→ Highlight benefits of ANC through home visits by
HEW/VCHW
→ Standardize program for outreach, targeting pregnant
women
→ Maternity waiting homes where there are facilities
providing 24/7 CEmONC services for women with previous
c/sections, very poor obstetric history and teen age
pregnancy
→ Increase knowledge and develop skills of women to avoid
unwanted pregnancy, seek safe abortion services and
recognize abortion complication
→ Use BPCR plan counselling card as a strategy to increase
demand for institutional birth
→ Address community level attitude of shame on responding
to emergency
→ Work with communities to develop local means of
transport and securing fund for use during emergencies
→ Increase capacity of volunteers and CBOs in raising
emergency funds and improving communication
Labor and delivery, up to 24 hours
√ Safe and clean Ω Low attendance of delivery ∞ Inadequate training of HEWs, pre-and in-service, → Proper training of HEWs on safe and clean delivery and
delivery by HEWs by HEWs on safe and clean delivery neonatal resuscitation; emphasis on proper site selection for
Ω Few HEWs trained on safe ∞ Lack of kits and other essential supplies for training with adequate case load, trainers and training
24 | P a g e
√ Prevention and and clean delivery delivery at health post level materials. Ensure that HEWs observe ten and attend five
treatment of PPH Ω HEWs are not trained on ∞ Lack of trust/confidence on HEWs skill, young deliveries during the training
using misoprostol IMNCI, on assessment of women are not accepted to attend deliveries in the → Prioritize labor and delivery and newborn care in
complication/illness community guidelines for HEP
Ω Low level of deliveries ∞ HEWs are not using TBAs when attending labor → Support HEW to prioritize high risk populations within
√ Immediate attended by skilled attendant and delivery the community and schedule work accordingly through in-
newborn care; Ω Low level of institutional ∞ No skilled assistant for those cases that require service training and supportive supervision
resuscitation if deliveries resuscitation, lack of knowledge on simple steps → Encourage HEWs to attend deliveries with TBAs, build
required, thermal Ω Delay to initiate breast that can be taken confidence in the community
care, hygienic feeding ∞ Delay in communicating onset of labor → Promote essential newborn care, awareness of danger
cord care, early Ω Unhygienic practice of cord ∞ Belief on possible treatment of bleeding through signs, timely care seeking through HEW, VCHW and kebele
initiation of breast care traditional means advocacy groups
feeding Ω Lack of proper practice on ∞ Low knowledge of availability and benefit of → Empower HEW to organize communities/advocacy
immediate thermal care obstetric services at a facility groups/fund committees – explore avenues for collective
Ω Limited experience of ∞ Negative attitude of males and other community action
√ Emergency saving or accessing fund for members for institutional delivery care → Community conversation on MNH
newborn care for emergency, through women’s ∞ Community does not think it is necessary to → Extend the role of model families to discuss maternal
complication; association have a facility delivery issues in a group
recognition and Ω Limited infrastructures, ∞ Baby not attended to until placenta is expelled → Establish system for labor/delivery notification (HEW-
taking action for roads and vehicles. The main ∞ Bathing baby seen as good hygiene and cold VCHW-health committees), use of communication media like
neonatal modality of transport is local water good to fatten baby mobile phones or radio, community volunteers or others.
complications stretcher with relay teams ∞ Expression of first milk – colostrums seen as → Improved and use of telecommunication network for
Ω Delivery services are dirty, not fit for babies emergency purpose at community level
mostly free in the public ∞ Lack of awareness of danger signs/ complications → Use telecommunication rural expansion program to avail
facilities ∞ Most women seek care from traditional sources telephone for all health posts to enhance communication and
∞ Poor transportation and roads impede women referral.
from going to health institution → Radio communication at health post/kebele level
∞ Financial problem to access transport services → Use volunteers and other community groups to inform
∞ Interpretation of health care financing is HEWs and facilitate proper care for mother in labor and
disrupting the implementation of fee exempted delivery
services → Use community level social network for accessing
∞ Limited communication facilities from emergency fund
household, HEWs and facility level → Promote and strengthen community-based support groups
∞ Low level of comfort and companionship at a (idir, ekub) to address issues related to maternal/newborn
facility deaths, for emergency transport, and financial support
∞ Preference for female providers → Establish a system of providing vouchers and social
∞ Improper reception and attitude of providers insurance schemes for institutional level delivery care
and other staffs, including support staff , health
25 | P a g e
facility → Support community level innovative transport services;
∞ Distance from the facility and settlement of the improved cart, motor cycles, bicycles ambulance and others
population → Advocacy group to identify and mobilize transport and
resources (private partnership)
→ Ambulance at health centre level
→ Encourage presence of companion during labor and
delivery at the home and facility
→ Presence of at least two birth attendants (one specifically
for the newborn)
→ Focus on prolonged labor identification, recognition and
means to address it at community level
→ Design and implement a system of motivating staff
providing maternity care
→ Use of Misoprostol by HEWs to manage 3rd stage labor,
less pulling on the cord
→ Increase HEW credibility through improved enhanced
service package (e.g. clean and safe delivery, management of
infections at community level) and assure quality through
regular standardized supportive supervision.
→ Introduce community data generation for decision making
to address maternal/neonatal care and link with regular
feedback meetings between community, HEW and health
center to identify priority actions.
→ Establish community epidemiological surveillance and
maternal-perinatal audits
→ Ensure priority indicators related to maternal and
neonatal health included in the annual action plan (e.g., HEW
assistance at delivery, PNC visit <24 hrs and within first
week)
→ Improve availability of essential drugs and commodities at
health post and health centers.
→ Improve HEW effectiveness by strengthening
collaboration with trained TBAs and linkages with selected
health facilities
→ Coordinate with education sector (schools) on MNH
promotion
26 | P a g e
Postpartum and neonatal care, day 1 to 28 days
√ Prevention and Ω Low use of postpartum ∞ Inadequate number of HEWs → Home visits of at least two for Post partum visit of
detection of care ∞ High work load of HEWs women after delivery on day 1 and day 3, if possible
complication Ω No or late visit to mothers ∞ HEW are not there at the critical time-24-48hrs day 7
(haemorrhage after deliver by HEWs after delivery → Provide postpartum vitamin A
and sepsis) Ω Limited knowledge of ∞ Low priority to exclusive breast feeding by → Include as priority in annual action plans and community
HEWs in recognizing and HEW, VCHWs and woreda at planning level HMIS (displaying on wall charts and reports)
√ Postnatal care providing first aid to new ∞ Low commitment/motivation of HEW → Make interventions related to postpartum among
visit within 24 born illness ∞ Lack of skill to recognize illness/infection in a priorities to be criteria of graduation for model family and
hours after child Ω Use of misoprostol by newborn topic for CC
birth HEWs and TTBAs; distribute ∞ Lack of awareness about the magnitude of → Shift some of HEWs task to VCHWs to focus on the
safely and effectively newborn illness and the consequences doable most critical interventions
√ Counselling on ∞ Lack of trust and confidence in the skills of → Develop/adapt simple harmonized and standardized
family planning HEWs messages and BCC tools
and where/how to ∞ Lack of awareness and knowledge among → Train HEWs and VCHWs on communication skills and
obtain families and community use of BCC tools –focused, skill based and standardized
contraception ∞ Lack of appropriate, simple, harmonized, doable trainings
messages and BCC/IEC tools → Establish/strengthen partnership for harmonization and
√ Exclusive breast ∞ Lack of harmonized and coordinated activities coordination among key partners and stakeholders
feeding amongst partners → Communicate using different appropriate approaches and
∞ Misperceptions/myths channels to deliver the messages
√ Thermal care ∞ Strong social/cultural beliefs that promote → Train mothers and families to recognize and give
harmful traditional practices- community leaders appropriate care for sick newborn
√ Hygienic cord and influential opinion leaders (TBAs, elder women → Improve collaborative working relationships between
care and men, grand mothers and religious leaders) HEW/HP and HF-critical review meetings between HEW,
reinforcing the HTP HW and community
√ Extra care for ∞ Young mothers in urban areas have peer → Increase HEW credibility through improved enhanced
small and LBW pressure about breast feeding in relation to service package and competence
mothers weight, breast shape etc → Promote self help groups such as social fund for support
√ Promote care ∞ Health problems of breast of poor households
seeking for illness ∞ Lack of support and encouragement from other → Promote and strengthen community based social support
family members-husband, grandmother, mother in groups (Idir, Ekub, insurance) for emergency transport,
√ Management of law financial support for medical related expenses
newborn illness ∞ Community HMIS and action plan doesn't → Introduce and strengthen community data generation and
include the high impact newborn interventions use for decision making (HMIS)
∞ Lack of awareness of available services in health
facilities among community
27 | P a g e
∞ Fistula patients are not well accepted
∞ Unsupportive relationships between HEWs and
Health Workers
∞ Very weak referral linkage between health post
and health centers
∞ Inaccessible service – physical barriers,
transport means and cost, hidden cost of
treatment at health facility
∞ Lack of appropriate community feedback
mechanism on status of health service delivery
28 | P a g e
Table 4: Strategic recommendations with priority intervention area by level of care
Strategic Recommendations Priority Intervention Area by Level of Care
Household Community Health Services
Develop capacities for self ≡ Extend the package for a model family ≡ Extend a model of community conversation and ≡ Encourage skilled care for at least
care, improved care seeking to include essential indicators of community mobilization for MNH; community 4 ANC visits; delivery and
behaviour and birth and maternal and newborn health dialoguing on critical MNH issues at a community immediate postnatal; postnatal visit;
emergency preparedness ≡ Promote use of skilled care; planning level obstetric and neonate emergencies.
for skilled birth attendant and prepare ≡ Increase knowledge and develop skills of women ≡ Design, produce and use in ANC
for early complication to avoid unwanted pregnancy, seek safe abortion of a birth and emergency
≡ Promote communication between care services and recognize abortion complications preparedness counseling card
couples and within the household to ≡ Increase awareness of signs of labor and ≡ Develop providers’- knowledge
support planning and implementation emergency for mother and newborn and communication skills in birth
≡ Educate mothers and other family ≡ Promote essential newborn care, awareness of and emergency preparedness
members on recognition and proper danger signs and timely care seeking
care of sick newborn
Increase awareness of the ≡ Improve couple communication in Increase individual and social understanding of the ≡ Developing capacity of health
needs and potential problems planning and joint decision making needs, risks and danger of pregnancy, childbirth and system to effectively deliver health
of women and newborns ≡ Improve involvement of men in care postpartum periods education
during pregnancy, labor and for mothers and newborn during ≡ Establish a system for pregnancy and labor/delivery ≡ Improve set up of facilities and
delivery and in the pregnancy, labor and delivery and notification. Work with the community so that providers skill on counseling
postpartum period postpartum HEWs identify pregnant mothers early couples
≡ Introduce community data generation for decision
making to address maternal and neonatal health
≡ Introduce a system of community epidemiological
surveillance and maternal and perinatal death audits.
29 | P a g e
Strengthen linkages between ≡ Ensure knowledge of danger of ≡ Strengthen collaboration of HEWs with health ≡ Strengthen the capacity of TBAs
the community and the health prolonged labor and when/where to go providers, community health workers and traditional in recognizing problems and when
delivery system for care birth attendants to ensure the continuity of care and necessary to guide women to and
social support through the formal health system
≡ Encourage HEWs to attend deliveries with TBAs; ≡ Establish maternity waiting area
builds support within the community in facilities where there is 24/7
≡ Develop local means of transport for use during CEmONC services
emergencies and means on how to cover cost
≡ Build capacity and facilitate use of community level
social network for accessing emergency fund
Improve access and quality of ≡ Immediate postnatal home visit, ≡ Expand outlets for family planning including social ≡ Improve method mix of
MNH services within 24hours, a second visit on the marketing of contraceptives contraceptives including LAPM
third day, and if possible a third visit on ≡ Prioritize labor and delivery and neonatal ≡ Improve set up of facilities to be
day seven by HEW resuscitation in the guidelines for HEP client friendly
≡ Proper competency based training of HEWs on ≡ Advocate for establishing policies
safe and clean delivery and neonatal resuscitation that promote social support during
≡ Scale up use of misoprostol by HEWs to manage labor
3rd stage labor ≡ Encourage presence of
≡ Increase men and community awareness of the companion during labor and
value of social support during child birth delivery
≡ Build communication and counseling skill of HEWs ≡ Encourage presence of at least
≡ Organize standard outreach program with proper two birth attendants (one
schedule specifically for newborn
≡ Build interpersonal and
intercultural competencies of
health providers
30 | P a g e
Annex 1: List of working group members
1. Wuleta Betemariam JSI/L10K

2. Dr Ashebir Gaym ESOG
3. Dr Solomon Tesfaye Consultant
4. Meselech Assegid FMOH
5. Dr Ahmed Abdella AAU
6. Dr Alemayehu Mekonnen SPH-AAU
7. Dr Hailemaraim Legesse IFHP
8. Dr Assaye Kassie Unicef
9. Dr Nebreed Fessha Jhpiego
10. Dr Tedbabe Degafu SCF/USA
11. Brain Mulligan JSI/SNL
12. Dr Samuel Teshome SCF/USA
13. Dr Solomon Kumbi ESOG
14. Dr Mulu Muleta UNFPA
15. Dr Muna Abdella UNFPA
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Annex 2: Workshop agenda
ADDRESSING COMMUNITY MATERNAL AND NEONATAL HEALTH IN ETHIOPIA: EVIDENCE-
BASED RECOMMENDATIONS FOR INCREASED DEMAND, ACCESS TO AND USE OF SERVICES;
MAY 12 – 14, 2009
Tuesday
May 12, 2009
Time Topic Session Objective Presenters
Opening and Introduction:

Facilitator: Wuleta Betemariam, JSI/L10K
Dr. Ashebir Gaym
09:00 -09:45 Welcome and Opening Address President, ESOG
AM Dr. Mary Taylor
Senior Program Officer, Bill
and Melinda Gates
Foundation
Dr. Keseteberhan Admassu
Director General, Health
Promotion and Disease
Prevention Directorate,
FMOH
Workshop objectives and agenda Dr. Solomon Tesfaye,
Consultant, L10K
Setting the Stage – Causes of maternal and newborn death in Ethiopia
Chair : Dr. Leuwi Pearson, UNICEF
09:45-10:05 AM Maternal death in Review maternal deaths -- trend, Dr. Ahmed Abdella,
Ethiopia causes and socio-demographic Instructor, AAU
variables at hospital and
community levels
10:05-10:25 AM Newborn death in Level of mortality and associated Dr. Alemayehu Mekonnen,
Ethiopia factors Instructor, SPH-AAU
10:25-10:45 AM Discussion
10:45-11:00 Tea Break
AM
Plenary 1: The HEP – Strategy for addressing maternal and newborn health
Chair: Ato Mequanet Tesfu, UNFPA
The HEP: Strategy Providing broader context of Messelech Asseged
11:00-11:30 AM for addressing HEP; HEWs actions on M&NH, Officer, Agrarian HEP
M&NH. differences they make in the FMOH
community.
HEW- role in Role of HEW for ANC, delivery, Dr. Ali Karim
11:30-12:00 PM maternal and postnatal care: model families, M&E Technical Advisor
newborn health community volunteers/TBA, HC , JSI-L10K
referral and others
12:00-12:20 PM Reflection and Regional Health Bureau RHBs
discussion Experience
32 | P a g e
12:20-12:30 PM Framework and work group assignment Dr. Marge Koblinsky,
Senior Technical Advisor, JSI
12:30-2:00 PM Lunch
Poster session Exploring more ideas and lessons learned
- JHPIEGO - HEWs (Afar, Amhara, Oromia,
SNNP, Tigray)
- AMREF -IntraHealth
Group work: Making it work – HEW and her surroundings
Lead person: Dr. Tesfaye Bulto, IFHP
02:00-3:30 PM Possible HEW efforts with and without referral support
03:30-4:00 PM Report out conclusions from working groups
04:00-4:30 PM Tea Break
04:30-5:00 PM Discussion Surprises and/or lessons learned
Wednesday
May 13, 2009
Time Topic Session objective Presenters
Plenary 2: Community care seeking for maternal health
Chair: Dr. Solomon Kumbi, AAU
9:00-9:30 Maternal health Findings from community based Dr. Charlotte Warren,
study; National and regional Population Council
9:30-9:50 Family planning Findings from L10K baseline Wuleta Betemariam, JSI-L10K
study in Amhara, Oromia,
SNNP and Tigray Regions
9:50-10:10 Post abortion care Demand and barriers in use of Dr. Solomon Tesfaye,
service Consultant
10:10-10:30 Discussion
10:30-11:00 Tea Break
Plenary 3: Community efforts to save mother lives
Chair: Dr. Marge Koblinsky, JSI
11:00- 11:20 Prevention of Causes of maternal mortality; Dr. Mulu Muleta, UNFPA
prolonged labor Outcomes, consequences of
prolonged labor/obstetric
fistula and care seeking;
eclamlpsia, maternal infection
11:20-11:40 Danger signs: What Danger sign recognition; Dr. Lynn Sibley,
families and home HBLSS—bleeding, prolonged Emory University
providers can do labor, birth asphyxia; role of
TBA
11:40-12:00 Community PPH: Community level Dr. Ashebir Getachew, Ghandi
Perception and perceptions and actions Hospital
action on PPH
12:00-12:20 Prevention of Lessons of pilot interventions Dr. Tesfanesh Belay, Venture
bleeding at community level Strategies
Use of Miso by HEW
33 | P a g e
12:30-02:00 Lunch
Poster session Exploring more ideas and lessons learned
- ESOG community intervention
- ESOG community study
- Use of Miso by TBA’s
- Health and Mobility (Transport)
Plenary 4: Community care seeking and efforts to save newborn lives
Chair: Professor Bogale Worku, AAU, EPA
2:00-2:20 Neonatal health Household practices in Brian Mulligan, SNL
services newborn care
2:20-2:40 Neonatal survival Community level Interventions Dr. Assaye Kassie, UNICEF
for Neonatal Health
3:00-3:30 Tea break
Group work: Community Intervention
Lead person: Dr. Nebreed Fisseha, JHPIEGO
Community mobilization and communication/transport (e.g., Community
conversation/dialogue, danger sign recognition, triggers for action, model families and
family health card)
3:30-4:50 Maternal care--Delivery, prolonged labor ; PPH and
emergent danger signs;- Family planning, post abortion
care
Newborn care--Birth asphyxia and breast feeding,
Infection prevention (thermal care, hygiene)
4:50-5:30 Report out conclusions from working groups
6:00-8:00 Reception, Hilton hotel
Thursday
May 14, 2009
Time Topic Session Objective Presenters
Plenary 5: Supporting community MNH: what support can facilities provide to community
efforts/referral support
Chair: Dr Tekleab Mekbib, Population Council
09:00-9:30 Facility support Results from national Dr. Barbara E.Kwast, AMDD
EmONC baseline
assessment
09:30-9:50 Lessons from facility Preparing health facilities Dr. Muna Abdella, UNFPA
level intervention as pre-requisite for
trained health staff
assignment
09:50-10:10 Supporting Process for PI; site Dr. Nebrid Fesseha, JHPIEGO
accelerated training assessment findings,
of Health Officers on training and other
BEmOC training intervention
34 | P a g e
10:30-11:00 Tea Break

Working groups – Referrals to hospital and health centre levels by pre-pregnancy,
11:00- 1:00 pregnancy, labor/delivery, postpartum
Discuss conclusions (e.g., barriers, prioritize barriers, conclusions etc)
Stratify conclusions by Maternity periods, referral possibilities

Poster session Explore more ideas and lessons learned
- Ginnir hospital
- Fistula hospital; MW training
- Atat hospital
- Maternity World Wide
1:00-3:00 Lunch
Final recommendations and preparation by small working groups; Pre-pregnancy,
pregnancy, labor/delivery, postpartum
Plenary 6: Recommendations and Closing
Chair: Dr. Ashebir Gaym, ESOG
Final report out/recommendations (stakeholders Dr. Nebreed Fisseha, JHPIEGO
3:00-5:00 join) Dr. Tedbab Digafe, Save – US
Closing remarks Dr. France Donnay
Senior Program Officer
The Bill and Melinda Gates Foundation
Dr. Negist Tesfaye Director, Urban
Health Extension Program,
FMOH
35 | P a g e
Annex 3: List of workshop participants
S/N Name of Participant Name of Organization e-mail address

1 Abeba Gebremariam Save abebegmariam@yahoo.com
2 Abera Workneh JSI / L10K - Oromia aworkneh@jsi-ltenk.org.et
3 Aberash Belete Tigray Regional Health Bureau berashi2006@yahoo.com
4 Abigal Teklu Facilitator abidilet@yahoo.com
5 Abusmo Mekonnen Benshangul Gumuz RHB -
6 Addisalem Debebe Health Extension Worker -
7 Ahmed Abdella AAU ahmedamu@yahoo.com
8 Alemayehu Mekonnen SPH - AAUMF alemayehuem@yahoo.com
9 Alemayehu Seifu AMREF alemayehu.seifu@amref.org
10 Alemnesh Tekleberhan Jhpiego atekleberhan@jhpiego.net
Gambella Regional Health
11 Alemu Tilahun Bureau alemut2006@yahoo.com
12 Amano Erbo JSI / L10K - Oromia aerbo@jsi-ltenk.org.et
13 Animut Anteneh FGAE animuta@fgaeet.org
Hamlin College of Midwives
14 Annette Bennett A.A Fistula Hospital bennett.a@hamlinfistula.org
15 Ann-Kristin R.Berget NLM / EECMY agberget@nlm.no
16 Asefaw Getachew MACEPA / PATH asefaw2000@yahoo.co.uk
17 Asheber Gaym ESOG ashebergaym@yahoo.com
18 Assaye Kassie Unicef akassie@unicef.org
19 Ataklti Berhe Unicef aberhe@unicef.org
20 Ayalew Asres Negadras News Paper -
21 Ayenew Messele Unicef - FMoH amessele@unicef.org
SNNP Health Extension
22 Aynalem Getachew Worker -
23 Barbara Kwast AMDD b.e.kwast@planet.ne
24 Barbara Pose CARE poseb@care.org.et
25 Berhane Assefa FMoH birishmoh@yahoo.com
26 Berhanu Asfaw MoH (c/o) keseteadmasu@yahoo.com
27 Berhanu Huluneh Freelance Consultant bantamfn@yahoo.com
28 Betel Zerihun AAU betybeti@gmail.com
29 Bethel Girma FMoH betgir2@yahoo.com
30 Bizuhan Gelaw JSI / L10K - Amhara bgelaw@jsi-ltenk.org.et
31 Bizunesh Tesfaye IntraHealth International btesfaye@intrahelath.org
Ethiopian Pediatric
32 Bogale Worku Association bogalewo@yahoo.com
33 Bogaletch Gebre KMG kmgselfhelp@ethionet.et
34 Brian Mulligan JSI / SNL bmulligan@healtheth.org.et
36 | P a g e
35 Charlette Warren Population Council cwarren@popcouncil.org
36 Chiryere Omeogu USAID Ethiopa cameogu@usaid.gov
37 Christel Ahrens FIDE, EECMY Health christel.ahrens@gmail.com
38 Disha Ali JSI - Deliver dali@jsi.com
39 Elaine Kohls ECS Emdeben st.lukehospital@ethionet.et
40 Elzabeth Gebretsadik HCP egebretsadik@aed.org
41 Eskinder Teshome JSI / L10K - Oromia eteshome@jsi-ltenk.org.et
42 Feleke Mulatu ENMA mulatu43@yahoo.com
Feven Tassew
43 CARE - Ethiopia fevent@care.org.et
44 Fitsum Demeke IntraHealth International fitse75@yahoo.com
45 Fran Tain JSI / Boston ftain@jsi.com
46 Franchesca Stuer FHI fstuer@fhi.org.et
47 Gaetano Azzimonti Wolliso Hospital g.azzimonti@cuamm.org
48 Gordon Williams Fistula Hospital gorwilliams@yahoo.com
49 Hailemariam Legesse IFHP hailemariaml@yahoo.com
50 Hamere Denussie ARC hamered@etharc.org
51 Hannah Gibson Jhpiego hgibson@jhpiego.net
Oromia / Health Extension
52 Jemila A/Jebel Worker -
53 Kemal Abdi Harari Regional Health Bureau habeekemal@yahoo.com
54 Kesetebirhan Admassu FMoH keseteadmasu@yahoo.com
55 Luwei Pearson Unicef lpearson@unicef.org
56 Lynn Sibley Emory University lisbley@emory
57 Marge Koblinsky JSI mkoblinsky@jsi.com
58 Mamo Gebretsadik FHI MGTsadik@fhi.org.et
59 Mayet Hailu DKT Ethiopia mayethailu@dktethiopia.org.et
60 Medhanit Wube FHI mwube@fhi.org.et
61 Melaku Gebissa IntraHealth International mgebissa@intrahealth.org
62 Melese Zewdie KMG melezw@yahoo.com
63 Mequanent Tesfu mtesfu@unfpa.org
64 Meselech Assegid FMoH meselua@yahoo.com
65 Mily Kayongo CARE – USA mkayongo@care.org
66 Mulu Muleta UNFPA mulumuleta@yahoo.com
67 Nebreed Fesseha Jhpiego nfesseha@jhpiego.net
Southern Regional Health
68 Omar Ahmed Abdi Bureau omarnn5@yahoo.com
69 Peter Eerens IFHP peerens@ifhp.et.org
70 Reta Tilahun IntraHealth International rtilahun@intrahealth.org
71 Rita Schiffer Attat Hospital attathospital@ethionet.et
72 Sahle Sita SNNP Regional Health Bureau sitasahle@yahoo.com
73 Samson Assefa IntraHealth International sassefa@intrahealth.org
37 | P a g e
74 Samuel Teshome SCF / USA sam.teshome2002@yahoo.com
75 Solomon Kumbi ESOG solomonkumbi@yahoo.com
76 Solomon Tesfaye Consultant soltesabe@yahoo.com
77 Sophia Brewer USAID sbrewer@usaid.gov
78 Swawa Byne Woliso Hospital wawa_msh@hotmail.com
79 Taye Berhanu ENFRTD tayeberhanu@hotmail.com
80 Tedbabe Degafu SCF / USA tdegafie@savechildren.org.et
81 Tekleab Mekbib Population Council tmekbib@popcouncil.org
82 Tesfanesh Belay USMD / DKT tbadale@yahoo.com
83 Tesfaye Bulto IFHP tbulto@ifhp.et.org
84 Tesfaye Shigute JSI / L10K – South tes_shigute@yahoo.com
85 Tewabech Gebrekirstos JSI / L10K – Tigrai tgebrekirstos@jsi-ltenk.org.et
86 Tigest Alemu MVPs tigestalem@yahoo.com
Tigray Health Extenstion
87 Tsige Abraha Worker -
88 Wassie Lingerih IFHP wlingerh@ifhp.et.org
89 Wongel Teketel A.A Regional Health Bureau dr.wongel@yahoo.com
90 Woutje Wahinge Unicef woutjeaddis@yahoo.com
91 Wuleta Betemariam JSI / L10K - Central Office wbetemariam@jsi-ltenk.org.et
92 Yemeserach Belayneh Packard Foundation ybelayneh@packard.org
93 Yimam Abegaz Gambella Health Bureau yimamabegaz@yahoo.com
94 Yoseph W/Gebriel USAID ywoldegabriel@usaid.gov
Afar Health Extension
95 Zehara Nega Worker -
38 | P a g e
The Last Ten Kilometers Project
JSI Research & Training Institute, Inc.
House # 2111, Kebele 03/05
Bole Sub-city, P.O.Box 13898
Addis Ababa, Ethiopia
Phone: 251-116-620-066
Fax: 251-116-630-919
E-mail: wbetemariam@JSI-LTENK.org.et

MNH Workshop Proceedings

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Addressing Community Maternal and Neona-

tal Health in Ethiopia. Report from National

Federal Democratic Republic of Ethiopian Society of Obstetricians &

LIST OF TABLES AND FIGURES II

2 MATERNAL AND NEONATAL HEALTH STATUS 8

3. HOME PRACTICES AND CARE SEEKING IN MNH 15

ANNEX 3: LIST OF WORKSHOP PARTICIPANTS 36

1. Review maternal and newborn health status in Ethiopia

Strategic recommendation 4: Improve access and quality of MNH services

1.2 Policy Environment:

1.3 National scoping exercise on the community component of MNH

1. Review maternal and newborn health status in Ethiopia

The section below summarizes:

2.1 Maternal outcomes

Figure 1: Trend of Maternal Mortality Ratio in Hospitals, 1970 to 2009

Trends in Major Causes of direct Maternal Deaths (Hospital Data)

Hemorrhage Eclampsia & SPE

2.1.2 Fistula—another major outcome of pregnancy

2.1.3 Service coverage to ensure maternal health

Increased coverage in the use of modern contraceptives by women of reproductive age in

2.2 Neonatal outcomes

Commun nity based data

The national EmONC facility baseline assessment in 2008/2009 indicated a perinatal

Figure 4: Causes of neonatal deaths

Estimated direct causes of neonatal death for

• Causes of neonatal deaths

2.2.1 Service coverage to ensure neonatal health

4. Efforts/Experience to Improve MNH at Community/Home Levels

In another 2006 community-based study of perceptions of HEP a year after implementation,

4.2 Community level

4.3 Facility level

5. Group Work: Conclusions and Recommendations

1. Wuleta Betemariam JSI/L10K

Opening and Introduction:

10:30-11:00 Tea Break

Stratify conclusions by Maternity periods, referral possibilities

S/N Name of Participant Name of Organization e-mail address

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