Intensified Efforts against Maternal Mortality : The case of Lanferao woreda Silte Zone

By Meskerem Lemma

The death of a mother is a tragic loss, not only for the family but also for the community and the country at large. Maternal mortality in developing countries and economically restrained settings still remains a daunting and largely unmet public health and global challenge. Globally,maternal mortality is unacceptably high. According to WHO 2012 data, about 800 women die of pregnancy- or childbirth-related complications around the world every day. In 2010, 287 000 women died during and following pregnancy and childbirth. Almost all of these deaths occurred in low-resource settings, and most could have been prevented.

More than 70 percent of maternal death is due to five major complications: hemorrhage, infection, unsafe abortion, hypertensive disorders of pregnancy, and obstructed labor.The high number of maternal death in some areas of the world reflects inequities in access to health services, and highlights the gap between rich and poor. Almost all or 99 percent maternal deaths occur in developing countries. More than half of these deaths occur in sub-Saharan Africa. The risk of maternal mortality is highest for adolescent girls under 15 years old. Complications in pregnancy and childbirth are the leading cause of death among adolescent girls in most developing countries. Women in developing countries have on average many more pregnancies than women in developed countries, and their lifetime risk of death due to pregnancy is higher. A woman’s lifetime risk of maternal death – the probability that a 15 year old woman will eventually die from a maternal cause – is 1 in 3800 in developed countries, versus 1 in 150 in developing countries.

Taking that into consideration, the National Guideline for Family Planning Services stated that all health institutions of the country be it rural and urban, hospitals, health centers, health posts, and both government-operated or private shall provide family planning (FP) services. FP services shall be delivered through the following service delivery modalities: Community and Facility-based services, social marketing and outreach services. In addition to outpatient clients, FP counseling and services should be made available to postpartum women, post abortion women, and individuals with special need the provision of FP services is dependent upon the integration of services throughout the health care system, starting from the community level to specialized referral hospitals.

The majority of Ethiopian women have the power to make decisions on issues related to the daily life of their family, but not on decisions about their reproductive health (RH) which depends on the will of men. Generally, the reproductive health needs the nation’s great concern. In recognition of this very high incidence, Federal Ministry of Health (FMOH) has put in place the 'Safe Motherhood Initiative'. The initiative, which is based on the principles of equity for women, primary health care and maternal care, has four main pillars: Family Planning, Antenatal Care, Clean & Safe Delivery, and Essential Obstetrics care, to be delivered through the provision of clean and safe delivery at the HEP level.
Maternal health is a useful indicator to assess not only women’s health status but also the accessibility, sufficiency and effectiveness of a country’s health service system. The world including Ethiopia is only two years from the pledge improving maternal health and reducing mortality rates from the 1990 level to 75 per cent by 2015. At the present, Ethiopia has made great progress in improving women and children health over the last ten years. According to the 2011 Ethiopian Demographic Health Survey ( EDHS) data child mortality has virtually halved in from 166 per 1,000 live births in 2000 to 123 live births to 88 per 1,000 live births in 2011compared to that of 2005 largely due to the health extension programme spearheaded by the MOH. But there are significant pockets of concern when it comes to the developing regions, for instance, Afar has 127 while it is 169 in Benishangul-Gumuz compared to Addis Ababa's 53 per 1,000 live births. While, maternal mortality ratio has dropped from 1,068 maternal deaths per 100,000 live births in 1990 to 871 in 2000 to 673 in 2005 to 676 in 2011 showing slight increase.

One good example that can compliment the success story is LanFero Woreda in Silte Zone in particular Gerare Warkse kebele. The kebele has a population of 5,213 out of which 1215 are women and 1421 children. Niejat Sahilu, 18, a seventh grader and a mother of two is a resident of the kebele. “I use contraceptive (Implanol). My daughter is four and my son is one. I am able to space my children birth because I am aware of the benefits spacing children from the kebele Health extension workers (HEW,” she said. “I don't want to have any more children in the near future because I have a plan to go and work in the Middle East, ”she added.

According to her, the supply of contraceptive is quite adequate and also basic health care services are available including Saturday, in addition to the HEW home to home visit. Moreover, early marriage and female genital mutilation is not practiced in her kebele anymore, “I married to my husband on my own will.”

Shakira Kedir, 18 is also a mother a two year old girl and 1 year old boy and a resident of the same kebele. “I gave birth to both of the children safely and cleanly at the health post. I prefer Implanol to the pill in order to avoid forgetting,” she said.

According to her, all women of the village use contraceptives and space the birth of their children because of the continuous awareness and teaching about the advantages of FP by HEW. Furthermore, supply and usage of contraceptives and access to basic health care for our children and the community is high.

Zebiba Mohamed Redi is one of the two kebele's HEWs. “Let alone the women, men also understood and accepted the benefits of FP because of the intensive awareness conducted by stakeholders,” said Zebiba.
The health post provides health care services like pre and post natal care, delivery, contraceptive, vaccination and basic health care services to children and the community. According to her in the last five months 21 women from the kebele delivered at he health post while 29 and 70 started using Implanol and Depo respectively.
“We also have enough supply of contraceptives and other medication for basic health care,” she said.

So far we are at zero incident level in terms of mother or child death during birth,she said adding, in case of complications using we refer them to the health stations with the ambulance service available. We have a referral linkage with all health posts and stations in the woreda.

Now, the number of women delivering at the health posts is increasing from time to time because, the law forbids the use of traditional birth attendants during delivery. We also used to deliver babies at homes but now they are coming to us, again because of awareness, Not only that, mothers also do monthly pre natal and post natal checkup and show up at appointments. In addition to that the kebele women have a forum held every month that discussions safe delivery and related issues, Zebiba added. According to her, all boy and girls from the the age of six go to school and Female Genital mutilation and early marriage is not exercised anymore. If a father committed the act ,he would be imprisoned while the women it fined a 500 birr.

Mandefro Teme the woreda health bureau representative,said currently ,the worda health coverage is at 93 percent. The woreda five health stations and 25 health posts for the over 137 thousand population. Delivery in health facilities and contraceptive usage by the women are in the increase from time to time ,for instance ,in the last six months alone some 1,342 women delivered while 1,222 used Implanol the preferred contraceptive type by the women. However, despite high contraceptive usage birth rate is high in the wore,he add.

According to him, Save the Children is working closely with us by providing capacity building,training, and providing materials and inspection that brought change in the reduction of child and maternal mortality in the woreda. In particular, quality basic medicine and equipment useful to have to a safe and clean delivery: one ambulance,five motorcycles and nine computers that help us to have computerized health information system and create linkage between health facilities “Save the children support is vital to the community,especially to mothers and children, I would like to ask them to continue their support,”Mandefro added.

Woreda Save the Children coordinator Chiksa Sultan said, Save the children is working in collaboration with the woreda health bureau in ensuring safe and clean delivery by filling gaps in medicine ,equipment and in capacity building and creating referral linkage between the community and health facilities. In addition we also do supervision and inspection and followup and helped create the health information system. According to Chiksa, Save the Children contributed some 3mln birr to child and mother health improvement in the woreda.

Despite the exemplary progress and government commitment to improve maternal and child health still the country has one of the highest maternal mortality figures in the world and only 9.9 percent of women are delivering in a health facilities. And still contraceptive usage,supply and demand is still very low. The National Fertility Survey(NFS) 2011 showed contraceptive prevalence increased from 5 per cent in 1990, to 8 per cent in 2000 to 15 per cent in 2005 to 28.6 per cent in 2011. This latest surge in uptake is due mainly to the new free contraceptive access service started in 2005, provided by MOH and the development partners. However, the same source also reveled that currently 25 per cent women of the county who want to space their births or have no more children have unmet need for family planning (lack of contraceptives) in particular among the youngest and married women in rural areas.

It is obvious that meeting the 25 percent unmet need for modern contraceptive methods will have an immediate impact in decreasing unintended pregnancies whose outcome could be unwanted babies , postpartum hemorrhage or unsafe abortion which are major causes of maternal mortality. In addition to increase awareness to increase delivery at health facility, the number and salary of HEWs and providing means of transportation eliminate existing inequities and barriers to women in the workforce should be eliminated, and women's participation in all policy-making and policy implementation should be promoted and strengthened. So should their access to productive resources, their ability to own land and their right to inherit property. It also should invest in, promote, monitor and evaluate the education and skill development of women and girls and the legal and economic rights of women.