The Obstetrician & Gynaecologist 2007;9:2:121-126
doi: 10.1576/toag.9.2.121.27314
Copyright © 2007 by the Royal College of Obstetricians and Gynaecologists.
Obstetric haemorrhage in Gimbie, Ethiopia
Shane Duffy, DTM&H MSc MRCOG, Clinical Director1
1. Maternity Worldwide, Unit 9 Level 4 New England House, New England Street, Brighton, BN1 4GH, UK Email: shanepduffy{at}maternityworldwide.org (corresponding author)
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Abstract
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Key content:- The leading cause of maternal death in developing countries is obstetric haemorrhage.
- The developing world has benefited little from the many medical advances of the last century.
- Health interventions in developing countries need to involve community as well as health facility interventions (the ‘three delays’ model).
Learning objectives:
- To understand the challenges of improving maternal health globally, especially in Ethiopia.
- To understand how developed countries can take the lead by funding change and by ethical recruitment from developing countries.
- To understand how a small charity, Maternity Worldwide, has started to address maternal inequalities in developing countries.
Ethical issues:
- Safe motherhood is not a charity issue: it is a call for justice.
- Developed countries have a responsibility not to actively recruit the scarce numbers of health care staff from developing countries.
Please cite this article as: Duffy S. Obstetric haemorrhage in Gimbie, Ethiopia. The Obstetrician & Gynaecologist 2007;9:121–126.
Keywords Ethiopia / maternal mortality / obstetric haemorrhage / three delays model
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Introduction
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More than 99% of all maternal deaths occur in the developing world and the great majority of these are avoidable.1 Women continue to die unnecessarily in pregnancy and childbirth in these countries: the most common cause is obstetric haemorrhage, which is estimated to result in 25–33% of all maternal deaths.2 In developed countries the maternal haemorrhage rate is 580 per 100 000 women, while in sub-Saharan Africa the estimated rate is 2 370 per 100 000 women.2
Despite the many medical advancements of the last century, the developing world has benefited little. If we are serious about stopping these unnecessary maternal deaths, with the proper resources and implementation we can build a future for these communities. In this article are presented some experiences of working in a rural part of Ethiopia – Gimbie.
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The global picture
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Little has changed since 1987 when the Safe Motherhood Initiative was launched by the World Health Organization (WHO). The initiative failed to reach its target of reducing maternal deaths by 50% by the year 2000. In 2000, the United Nations Member States adopted the Millennium Development Goals (MDGs).3 The eight MDGs are comprehensive in scope and aim to address the interlinked factors underlying poverty and global inequalities. Maternal and child health are priority areas in the Millennium Declaration. By 2015, the UN Member States have pledged to reduce (compared with the 1990 baseline):- the maternal mortality ratio (MMR) by three-quarters
- the number of children who die before their fifth birthday by two-thirds
However, despite increased advocacy, evidence-based interventions and international and community awareness, these targets may not be reached.
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The Ethiopian/Gimbie picture
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Ethiopia (Figure 1) is an impoverished country, with 63% of the rural and 53% of the urban population living below the poverty lines of US$23.00 and US$35.00 per person per month, respectively.4 Within the rural population, only 12% have access to safe water and only 7% to adequate sanitation.5 The life expectancy at birth is 46.3 years of age for women.6 Approximately 29% of women are malnourished (body mass index [BMI] <18.5) and 42% of children are underweight.7 The female illiteracy rate is very high, at 75%.8 Women have a low status within this society: 56% of them believe that a husband is justified in beating his wife if she leaves the house without telling him.8 Women are particularly disadvantaged during pregnancy and childbirth, with inadequate health service provision and a high risk of death or disability (Table 1).
Gimbie Town is situated in the West Wollega Zone, about 450 km west of Addis Ababa, a journey of approximately 12 hours in a four-wheel drive vehicle. The total population of West Wollega is approximately 2.03 million, of whom 35 000 live in Gimbie Town.
Maternal health service provision in West Wollega is woefully inadequate, with only 2.1% of births taking place in emergency obstetric care facilities. Additionally, the rate of caesarean section in West Wollega is approximately 0.4% of all births.9 These figures are inadequate compared with the WHO standard of a minimum of 15% of births requiring emergency obstetric care services and a minimum of 5% of women requiring caesarean section delivery.10
Maternity Worldwide has been working in Gimbie since 2003, providing a comprehensive safe motherhood programme, including the provision of essential obstetric care services and community health education and support of a network of income-generating women's groups. Maternity Worldwide's main hospital site is Gimbie Adventist Hospital, which serves a population of approximately 500 000 and provides 24-hour medical, surgical, paediatric, obstetric and gynaecology services. The hospital offers standard laboratory and radiography services as well as preventive and rehabilitative health care (physiotherapy). The obstetric service is provided by three midwives, eight senior nurses, three general practitioners, one general surgeon and one obstetrician. On each duty period there is either a midwife or a senior nurse to manage the labour ward with the assistance of a junior nurse and non-professional ‘practical worker’. In addition to covering the labour ward, the nurse/midwife is responsible for up to 20 other female medical and surgical patients. The obstetrician and general surgeon work alternate days on call for obstetrics.
In 2005, there were 628 obstetric admissions to Gimbie Adventist Hospital, including 595 deliveries.11 A large proportion of births were complicated, as shown in Table 2. In that year, eight maternal deaths were recorded among the women admitted, giving a case fatality rate of 1.3%. Three of the maternal deaths were the result of obstetric haemorrhage.
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Understanding the challenges of obstetric haemorrhage in resource-poor settings
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In developing countries an understanding of public health determinants is integral to the success of any intervention to reduce maternal mortality, in addition to an understanding of the biomedical causes and management of obstetric haemorrhage. Timing is critical in preventing maternal death and disability. Using the ‘three delays’ model (Figure 2) and the time to death for obstetric emergencies (Table 3), we have started to address the changes in health planning that need to be instituted to prevent obstetric haemorrhage-related deaths in Gimbie.
The first two delays
A delay in seeking and reaching appropriate care relates directly to the issue of access. It encompasses factors within the family and in the community, including a woman's status, health care costs and distance from health facilities and transportation. In Gimbie, communities have little knowledge of life-threatening pregnancy complications and, even when a complication is recognised, the costs of medical treatment may discourage attendance at health facilities. Additionally, most of the population live in villages located many kilometres from Gimbie Adventist Hospital (Figure 3), with no road transport and muddy, mountainous terrain to be crossed. Women are carried to hospital on improvised stretchers (Figure 4), a journey that can take many hours. It is not uncommon for women to remain at home, in labour, for 3 or 4 days before seeking medical care, with a resulting high rate of fetal death and ruptured uterus.
To address these factors, Maternity Worldwide has developed a network of women's groups, a ‘Safe Birth Fund’ and a health education programme to encourage timely health-seeking behaviour.
Women's groups
To date, seven women's groups, with 224 participants, have been established. Through the groups, women participate in a range of income-generating projects to increase their financial independence and ability to command resources. The groups act as the focal point for health education and promotion.
The Safe Birth Fund
To help break down socioeconomic barriers to essential obstetric care, in 2003 Maternity Worldwide established the Safe Birth Fund, which operates as a voucher scheme. The fund provides subsidised medical care to woman with complications in pregnancy. Initially, the fund was administered through the women's groups but it subsequently expanded to the cover the entire female population of the 16 kebeles (rural villages), where it is administered by the elected village leaders.
Evaluation has shown that 53% of women receiving care through the Safe Birth Fund were admitted for conditions needing advanced obstetric care. The voucher scheme is aimed at encouraging women who need a skilled delivery to attend the hospital or clinics and does not target those who are expected to deliver safely at home. Of all admissions among women receiving care through the fund, 2.6% had an antepartum haemorrhage.
Health education and promotion
In Ethiopia the female illiteracy rate is very high, at 75% of the total female population.8 Community education has been employed successfully in safe motherhood programmes.12 Maternity Worldwide has developed a site-specific health promotion and education programme, initially delivered through the women's group network and subsequently extended to all villages participating in the Safe Birth Fund. In the last 6 months, community education has occurred in 16 kebeles (rural villages) with 1 228 attenders (Figure 5). The focus of the health education is to mobilise communities to take prompt action when maternal health problems occur and to encourage women, families and communities to plan in advance for emergency situations. We have not promoted antenatal care and risk screening, as this approach has limited value. Only 10–15% of women who are thought to be ‘at risk’ of complications actually go on to have a problem, while most women who do develop complications have no risk factors. The risk screening approach is costly and can give a false sense of security to those who are risk-negative.13 The community education programme deals not only with the signs of problems in pregnancy but wider issues regarding the ability to command resources, improving the mobility and decision-making capabilities of women.
The third delay
The delay in receiving high-quality care at health facilities relates to the number and skills of health professionals and the availability of equipment and drugs for emergency obstetric care. These are particular challenges in resource-poor countries. Ethiopia has a shortage of health professionals at all levels, including doctors, nurses and midwives, and poor clinical governance processes to monitor standards of health care. All three maternal deaths from obstetric haemorrhage at Gimbie Adventist Hospital in 2005 were, in part, the result of an inappropriate response of health professionals to documented abnormalities.
A further challenge in developing countries is that essential drugs and supplies can be difficult to obtain, with intermittent supplies and variable costs. This was highlighted recently by a national shortage of blood bags because of problems with importation at a national level. This resulted in many hospitals, including Gimbie, being unable to give blood transfusions.
A particular problem at many health facilities in Ethiopia, including Gimbie Adventist Hospital, is the absence of a blood bank. A woman who needs a blood transfusion must find a friend or relative willing to donate blood who has a compatible blood group. This leads to a delay in receiving appropriate care, since people are reluctant and afraid to donate blood among community members. One of our midwives donated three units of her own blood to prevent patients dying from haemorrhage while working at Gimbie. This fear about the safety of blood donation is also being addressed through the community education programme.
Maternity Worldwide has improved the quality of care that women receive by training staff from both Gimbie Adventist Hospital and clinics, introducing pathways of care, and by the provision of equipment and essential drugs. In addition, it seeks to increase capacity by deploying obstetricians and midwives from developed countries to Gimbie Hospital to provide care for women and to train local staff. In the last year we have had three obstetricians (two senior registrars and one consultant), three midwife trainers and one project manager working in Gimbie. Until now, most staff have been short term, staying between 3 and 6 months. In addition to the project manager, we have recently recruited two midwife trainers and one obstetrician on 2-year contracts, to provide a sustainable service and to act as trainers for local staff. We continue to seek midwives and obstetricians to work in Gimbie, ideally for a minimum of 6 months.
The clinical management of obstetric haemorrhage in Gimbie revolves around protocols similar to those in the West. However, since women in Gimbie tend to present to hospital much later, the protocols focus on initial resuscitation and emphasis is given to defining ‘normal’ and ‘abnormal’ and the actions that should be taken for any abnormal finding. This has led to the maternal health staff being more confident in dealing with obstetric emergencies and to greater accountability in treatment episodes.
The overall aim of the Maternity Worldwide programme is to increase the proportion of women with complications attending emergency obstetric care facilities and to improve the quality of care provided to reduce unnecessary maternal deaths.
A 1-year evaluation of the Safe Birth Fund and community education programme has shown that the proportion of births from the 16 participating villages that take place in the emergency obstetric care facilities has more than doubled, from 2.1% to 4.5%. Additionally, the obstetric case fatality rate at Gimbie Adventist Hospital in 2005 was 1.3%, compared with a baseline case fatality rate of 2.2% in the whole of West Wollega.9 These trends are encouraging but still fall far short of WHO targets.3
Given the fact that most births in West Wollega take place at home, remote from health facilities, and that death from postpartum haemorrhage occurs on average within 2 hours, there remains an urgent need to develop community-based interventions to reduce the incidence of postpartum haemorrhage.14 Within health facilities, recent findings of a 50% reduction of blood loss when using a non-pneumatic anti-shock garment are promising and may have a place in settings like Gimbie.15
The situation in Gimbie highlights the need for a comprehensive approach to safe motherhood programmes and addressing each of the ‘three delays’. However, there are many challenges and the amount of effort required to bring about change should not be underestimated.
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Summary
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To meet the Millennium Development Goals, Ethiopia will have to reduce its maternal mortality ratio to less than 450 per 100 000 by 2015. This is a particularly daunting challenge, since countries with a gross domestic product (GDP) per capita twice that of Ethiopia have almost universally failed to decrease their maternal mortality ratio below 400 per 100 000.16 The impact of Western technology in resource-poor settings is limited by cultural, societal and political factors, resources and infrastructure. The technologies and medications that exist need skilled staff. We believe that developed countries have a responsibility not to actively recruit the scarce numbers of health care staff from developing countries. Prevention of delays is aided by providing effective community education, transport and communication links, as well as fully equipped and staffed facilities.
In a report published in 2001,17 it is estimated that the cost globally of providing comprehensive maternal care services would be approximately an additional $4 billion spending per year. Although this seems a large amount of money, it is in fact only 0.01% of the GDP of the 30 Organisation for Economic Co-operation and Development countries and is equivalent to the amount of money the G7 group of the wealthiest nations spend on the military every 2 days. The financing of maternal and infant health cannot be viewed in isolation. An additional $27 billion would be needed to strengthen healthcare systems to the point where they can deliver basic health care packages effectively.
To prevent unnecessary maternal deaths, communities, public health workers, clinical staff, national government organisations and governments need to engage and work as an integrated team to implement practical and feasible essential obstetric care. With less advocacy and more action we can help to build a future for these communities.
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References
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- World Health Organization. Maternal Mortality in 2000: Estimates Developed by WHO, UNICEF and UNFPA. Geneva: WHO; 2004
- AbouZahr C. Antepartum and postpartum haemorrhage. In: Murray CJL, Lopez AD, editors. In: Health Dimensions of Sex and Reproduction: the Global Burden of Sexually Transmitted Diseases, HIV, Maternal Conditions, Perinatal Disorders, and Congenital Anomalies. Cambridge, MA: Harvard School of Public Health on behalf of the World Health Organization and The World Bank; 1998. p. 165–189.
- United Nations Millennium Declaration. [www.un.org/millennium/declaration/ares552e.pdf].
- Ali Abdel Gadir Ali, Chief, Economic and Social Policy Division. Keynote Address: Malnutrition in the Greater Horn of Africa: Scope, Issues and Challenges. United Nations Economic Commission for Africa (UNECA). Horn of Africa Regional Workshop: Agricultural Policy, Resource Access and Human Nutrition, Addis Ababa, Ethiopia, 3–5 November 1999. [www.ies.wisc.edu/ltc/live/basissem9911_keynote.pdf].
- United Nations Children's Fund (UNICEF). Statistics. [www.unicef.org/infobycountry/ethiopia_statistics.html].
- United Nations Population Fund (UNPF). [www.unfpa.org/profile/ethiopia.cfm].
- Department for International Development (DFID). Ethiopia: Country Assistance Plan 2003. Glasgow: DFID; 2003
- Central Statistics Authority [Ethiopia] and ORC Macro. Ethiopia Demographic and Health Survey Ethiopia 2000. Addis Ababa, Ethiopia and Calverton, Maryland, USA: Central Statistical Authority and ORC Macro; 2001
- Maternal Health in West Wollega: A description of the context evaluation of service provision and recommended action to reduce deaths in pregnancy and childbirth Maternity Worldwide Situation Analysis, May 2005. [Internal Maternity Worldwide document, available on request from Maternity Worldwide].
- Maine D, Akalin MZ, Ward VM, Kamara A. The Design and Evaluation of Maternal Mortality Programmes. Center for Population and Family Health, School of Public Health, Columbia University; 1997. [www.cpc.unc.edu/measure/publications/html/ms-02-09-tool10.html].
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- Manandhar DS, Osrin D, Shrestha BP, Mesko N, Morrison J, Tumbahangphe KM, et al. Members of the MIRA Makwanpur trial team. Effect of a participatory intervention with women's groups on birth outcomes in Nepal: cluster-randomised controlled trial. Lancet 2004;364:970–9. doi:10.1016/S0140-6736(04)17021-9[Medline]
- World Health Organization (WHO). Care in Normal Birth: A Practical Guide. Report of a Technical Working Group. WHO: Geneva; 1999
- Chandhiok N, Dhillon B S, Datey S, Mathur A, Saxena NC. Oral misoprostol for prevention of postpartum hemorrhage by paramedical workers in India. Int J Gynaecol Obstet 2006;92:170–5. doi:10.1016/j.ijgo.2005.10.019[Medline]
- Miller S, Hamza S, Bray EH, Lester F, Nada K, et al. First aid for obstetric haemorrhage: the pilot study of the non-pneumatic anti-shock garment in Egypt. BJOG 2006;113:424–9. doi:10.1111/j.1471-0528.2006.00873.x[Medline]
- The World Bank Africa Region Human Development and Ministry of Health Ethiopia. A Country Status Report on Health and Poverty. Washington DC: World Bank; 2004. [www.crdaethiopia.org/PolicyDocuments/CSR%20on%20Health%20and%20Poverty.pdf].
- World Health Organization (WHO). Macroeconomics and Health: Investing in Health for Economic Development. Report of the Commission on Macroeconomics and Health. Geneva: WHO; 2001. [www.cid.harvard.edu/cidcmh/CMHReport.pdf].
- Maine D. Studying Maternal Mortality in Developing Countries. A Guidebook: Rates and Causes. WHO: Geneva; 1987
- United Nations Population Fund. Providing Emergency Obstetric Care to All in Need. [www.unfpa.org/mothers/obstetric.htm].
TOP
Abstract
Introduction
