Nurturing maternal health in Ethiopia
University of Alberta doctors help deliver life-saving skills
Every year in Ethiopia, a Horn of Africa nation of nearly 92 million, about 25,000 women die in childbirth. All but a handful of those tragedies are unnecessary.
In Canada, with a population roughly one third that size, all but about 150 of those women likely would have been saved, often with techniques, equipment and organization that are neither difficult to obtain nor expensive to provide.
In 2012, an estimated 68 children in every 1,000 in Ethiopia died before the age of five — a depressing statistic, but still a vast improvement over the 204 who died in 1990. In 2011, the comparable rate in Canada was 5.6 child deaths per 1,000.
It’s important to consider that many women in the drought-prone, impoverished nation prefer delivering at home among trusted friends and family, where customs can be observed, according to a 2011 study published in the Ethiopian Journal of Health.
“Even though communities are aware of the dangers around childbirth, contingencies for potential complications are rarely discussed or made, such that most families hope or pray that things will turn out well,” the study said. “When things go wrong, precious time is lost in finding resources and manpower to assist in the transfer to a health facility.”
Last year, Health Ministry maternal health expert Frewoine Gebrehiwot was quoted as saying about 80 per cent of all maternal deaths in the country are attributed to infection, hemorrhage, unsafe abortion, hypertensive disorders, and obstructed labour, along with HIV/AIDS and malaria. And even for those who survive, at least 500,000 Ethiopian women and girls suffer other complications, such as obstetric fistula — a hole in the birth canal.
But soon most can be saved, thanks in part to a new maternal health initiative launched by a group of University of Alberta health- care professionals, who’ll help train and send 35,000 health extension workers into towns and villages. Supported by a $4.6-million aid grant from Ottawa’s new, consolidated Department of Foreign Affairs, Trade and Development, they hope to do in five years what it took countries like Canada decades to achieve in terms of saving mothers and newborns.
It’s a potential reduction of 99 per cent in the life-changing trauma to vast numbers of husbands and children, not to mention in the economic and emotional injury to communities and extended families.
Since its inception, the project has expanded from the U of A to crucial midwifery expertise from the Faculty of Health and Community Studies at Mount Royal University in Calgary, and further collaboration from the University of Saskatchewan, the Society of Rural Physicians of Canada and the Ethiopia North America Health Providers Association (ENAHPA).
But it might be said to have germinated in the experience of Ethiopian-born hematologist Dr. Melaku Game, who in his spare time has been president of ENAHPA for 12 years.
After a repressive Marxist dictatorship ended in 1991, skilled Ethiopian expatriates have been eager to give back to their homeland. Over the years, that’s exactly what Game’s group has done, pursuing projects in such areas as HIV/ AIDS medication, emergency medicine and onthe-scene handling of traffic casualties.
Those efforts have usually involved the sharing of expertise by North American specialists, but they have always focused on strengthening the skills and abilities of the local people rather than paternalistic, and unsustainable, direct intervention. Game describes the approach as a progression: “teach, empower, equip and exit.”
The first step was an exploratory trip last year to Addis Ababa by Game and Dr. David Zakus, the new director of global health in U of A’s faculty of medicine and dentistry (and co-author of this article). That led to a successful application to the Canadian International Development Agency, a body now part of the consolidated foreign affairs department.
Officials in the Ethiopian capital were the first to admit they worried about a shortage of experienced midwife teachers, and thus about the competence of the thousands of new midwives. Often, teachers for new programs were simply enlisted from the top ranks of the previous year’s midwifery class whose handson experience was limited to a mere handful of deliveries, when international standards called for at least 40. After consultations with Ethiopian partners — including the Health Ministry, St. Paul’s Hospital Millennium Medical College, the Ethiopian Midwives Association, the African Medical Research Foundation and the Ethiopian Public Health Association — the project team quickly identified the potential to “train the trainers.” Currently being developed by the Mount Royal group to begin early in 2014, it will entail 20 Ethiopian midwives a year participating in a four-month program involving both classroom and fieldwork. The goal is upgraded skills for delivery, referrals and newborn care rippling out to 1,000 teachers, and ultimately to thousands of front-line midwives.
In the fourth year, the whole program will be directed and delivered by Ethiopians rath- er than Canadians. A second goal relates to the referral process, that complex net of arrangements to ensure the seven to 10 per cent of mothers with non-ideal pregnancies — and the many newborns with their own difficulties — get timely emergency transport and care.
While the main focus so far has been on midwife-teacher training, it has become clear the referral project should focus on identifying the particular causes of bad outcomes, such as a decision not to seek outside care, failure to keep babies warm, the absence of timely emergency transportation, or an inability to meet the need at the clinic or district hospital receiving the emergency case. Dr. Khalid Aziz, a professor of pediatrics and member of the project’s leadership group, cites a focus on breathing problems, a common contributor to infant mortality.
Not long ago, women in distant villages were essentially as much on their own as our fore- bears were in the 19th century.
Now their country has reached the point where poor use of existing resources and a weak transportation system — poor roads, a major rainy season and inconsistent availability of vehicles — are meaningful problems for patients.
If Canada’s existing medical schools were all ordered to simply double their numbers of students in a year, they’d likely find it an almost impossible task. Yet here is Ethiopia, which over the last two decades has established more than 30 new universities and 20 new medical schools, now struggling to sort out the glitches associated with the sudden deployment of thousands of health extension workers and midwives to the farthest reaches of the country.
One basic issue is getting women to understand the potential for something going wrong with their pregnancy, then to trust the health system. Expectant mothers and their families may not always have faith in the services available — perhaps because of a previously bad experience, or because of service not delivered on a compassionate, friendly basis by poorly paid, overworked and ill-supported staff. In watching the opening phases of the project, a Canadian observer’s attention is initially captured by the drive of the Canadian players — none has time on their hands in their day jobs, and some are at that stage in their careers when resting on one’s oars might seem more natural.
Roger Turnell, a U of A professor of obstetrics and gynecology, passionately points to the appalling losses on a worldwide basis: one woman in childbirth dying every minute, two babies in the first 28 days of life dying per minute, and two babies stillborn every three minutes. In Canada, he says, the vast majority would live as a matter of routine.
Aziz, a neonatologist, talks of the roughly 10 per cent of babies born on this planet who are premature and may die if they enter this world somewhere they can’t be properly cared for. In Ethiopia, he learned that one major contributor to neonatal mortality is hypothermia — something that can easily be tackled. “Small babies can be kept warm just by being kept skin to skin with another human being. It’s ‘lowhanging fruit’ to save those children.”
Game’s passion for this and other projects underscores the progress his homeland has made in the last two decades, and the new government’s drive to push those gains on fronts ranging from agriculture and transport to energy, tourism and medical services.
“Far from putting impediments in the way, the government is eager; if they complain, it is that things aren’t happening fast enough,” he says.
But Zakus, who has his own passion for Ethiopia after having lived and taught there for three years in the 1990s, says the group’s inspiration is the drive of its crucial Ethiopian partners and the opportunity to address a key human rights issue.
“Health workers in Ethiopia’s public system are very poorly remunerated; they often need other jobs to get by; they do it because they are dedicated to their people and their country.
“We are putting ourselves out, travelling far to apply our skills. It is very inspiring how utterly motivated and committed people in Ethiopia are to making things better there.”