Evidence for Action (E4A) has worked across six countries in sub-Saharan Africa – Ethiopia, Ghana, Malawi, Nigeria, Sierra Leone and Tanzania – and regionally to improve maternal and newborn survival. Originally funded with UK Aid from the UK government, it is now funded by the Bill and Melinda Gates Foundation. To read more about E4A-MamaYe in other countries, click here.
Evidence for Action in Ethiopia
E4A has been providing technical assistance for the introduction, implementation and scale-up of Ethiopia’s national Maternal Death Surveillance & Response (MDSR) system since 2012. At national level, this has involved contributing to the development of the MDSR Guidance, data collection tools and database, and training curriculum, participating as active members of the MDSR task force, and representing the programme internationally.
The Ethiopia E4A team is based in the MNCH department of the WHO Ethiopia country office and led in Ethiopia by Dr Azmach Hadush. E4A is supported by regional Technical Advisors who have been supporting Amhara, Oromiya, SNNPR and Tigray, Harari, Dire Dawa and Addis Ababa, as well as a Data Manager working in the Ethiopian Public Health Institute (EPHI) Public Health Emergency Management (PHEM) directorate and a Perinatal Specialist. Options serves as the E4A Technical Support Unit, providing strategic guidance and 2 advisors based in Ethiopia.
Ethiopia’s MDSR system is unique in many ways – it is among the first in Africa to collect community based data from the start. Furthermore, MDSR has been integrated into the national PHEM surveillance system. Maternal deaths are now the 21st reportable condition on weekly PHEM reporting forms.
MDSR is a cycle of identifying and reporting maternal deaths, followed by collecting data, analysing it, and taking appropriate action at community, health centre, woreda, zonal, regional and national levels. At community level, each case is documented through a Verbal Autopsy, during which trained staff record information about the woman’s condition before her death, including delays in seeking, reaching, and receiving treatment.
A committee at the local health centre reviews each death to decide on its causes, determinants, and whether it was preventable. They summarise the information on a case-based Maternal Death Reporting Form (MDRF) for submission up the health system. Eventually, all the MDSR data reach the PHEM team at the Ethiopian Public Health Institute (EPHI) and are entered into the national MDSR database for further analysis, supported by E4A.
Engagement at community level is a critical element of a well-functioning MDSR system. Both community members and health service providers need to understand their role within the MDSR cycle and feel that there will be no negative repercussions for reporting or discussing maternal deaths. E4A has organised sensitisation meetings to ensure the message of “no blame, no shame” is adequately understood. For example, the photo to the right depicts a regional E4A Technical Advisor addressing a gathering of Women’s Development Army representatives to explain how the system works, its potential advantages, and how they can participate to ensure its success.
E4A has attended many review meetings and provided advice on how to interpret data and ensure it translates into responses to prevent future deaths. Some of the actions taken include deploying more ambulances from woreda health offices (and ensuring they are in good condition and filled with fuel), improving referral links to hospitals so that health centres are aware of where they should send critical cases and are provided with useful feedback following each death, and changing staffing arrangements to ensure midwives are available 24 hours a day, 7 days a week and other staff work where they are needed, such as overseeing the recovery room to monitor women who have undergone emergency obstetric care.
To share information about lessons learned across the system, E4A produces quarterly newsletters to highlight new developments and describe successful responses taken following maternal death reviews.
E4A organises continuing medical education seminars with the Ethiopian Society of Obstetricians and Gynaecologists to ensure MDSR is integrated into in-service training. E4A supported the production of a short film depicting the experience of MDSR in one community. It will be made available as a way to sensitise local people and frontline staff.
A cornerstone of E4A is the technical support provided at regional level to build and strengthen the system throughout the country. At the start of the programme, E4A focused on two zones within each large region in order to provide intensive supervision during the early stages of MDSR implementation. One of the key lessons from establishing and strengthening MDSR has been the need to provide consistent and regular on-the-job support, including ensuring full coverage of cascade training, distribution of tools and guidelines, and advice on how to complete data collection forms, structure review committees, conduct review meetings, and document findings and responses and report these up through all levels of the health system.
E4A has facilitated meetings to explain MDSR to different stakeholders, including religious leaders, local officials, surveillance officers and Health Development Army members.
A key goal is to develop collaboration between health services in different geographical areas, particularly as women who die in health facilities may come from surrounding areas located in another woreda, zone or even region.
E4A is continuing to support Ethiopia’s national MDSR system as it grows and develops, particularly as the system has now been rolled out across the country and additional training and support will be required. The latest developments include adding perinatal reviews and working with facilities to ensure they translate analysis from on-site deaths into quality improvement measures. As the national MDSR database continues to grow, E4A is supporting EPHI in providing useful and user-friendly data to the Regional Health Bureaus and the FMOH to support implementation of relevant components of the Ethiopian Health Sector Transformation Plan. E4A also builds the capacity of those working with MDSR data to analyse and interpret the data and make appropriate actions in response to the findings.
E4A is implemented by WHO and Options with funding from the Bill and Melinda Gates Foundation. Until March 2016, E4A was funded by UK Aid from the UK government and technical support was also provided by The University of Aberdeen.
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