Saving Women’s Lives in Rural Ethiopia by Task-Shifting Procedures to Clinicians

TIGRAY REGION, Ethiopia — “We are all looking to you to be a window of hope to reduce the unnecessary death of mothers and newborns during pregnancy and delivery in rural Ethiopia,” said Dr.Tedros Adhanom, the Minister of Health, as he handed over degrees to the first graduates at Ayder Hospital of his country’s programme in Integrated Emergency Surgery and Obstetrics.

The first graduating class of the new three-year Masters of Science programme, established by the Ministries of Health and Education with the support of UNFPA, included 16 health professional graduates at Ayder Hospital who will now be able to carry out Ceasarean sections and other procedures that were once strictly relegated to medical doctors. This strategy for dealing with the significant shortages of trained health workers, particularly in rural areas, is called task-shifting.

Aiming to deploy a trained clinician to every district

The Government’s ambitious goal is to deploy one trained obstetric non-physician clinician to each Ethiopian health district, as the country graduates 800 to 1,000 such professionals in the years ahead. Thirty-seven sites have been designated by the Ministry of Health using data from the emergency obstetric care survey conducted in 2009.

Though Ethiopia has had considerable success in reducing maternal deaths in the last decade  -- the maternal mortality ration has dropped by almost half in ten years, from 871 deaths per 100,000 live births to 470 -- a huge gap remains. Ethiopian women, the majority of whom live in rural areas, face multiple challenges in getting adequate care, however, as they often live far from health centres and transportation options are limited. Limitations on resources, including health workers, pose additional challenges. Rural women are the focus of the current Commission on the Status of Women.

Filling the gap in trained health workers

Only 51 per cent of hospitals in the country provide comprehensive emergency obstetric and neonatal care, while 14 per cent of health centres offer basic emergency obstetric and neonatal care. Only 10 per cent of women have access to a skilled birth attendant, and the country needs nearly 9,000 more skilled health workers to achieve 95 per cent coverage, according to the State of World Midwifery report.

Overcoming these challenges requires integrated policies and innovative programmes mandated by the highest level of government. The new training programme in emergency surgery and obstetric is critical in filling the gaps in rural health services and ultimately improving the well-being of mothers and their chances of survival during pregnancy and childbirth.

The MSc Programme is operating in five universities, Gondar, Hawassa, Haromaya, Jimma and Mekele, with 282 students enrolled. The programme shifts tasks from physicians to clinicians to address the shortages and inequalities in emergency obstetrics and neonatal care between rural and urban areas and rich and poor communities. UNFPA has contributed nearly $2 million worth of financial, technical and material support to the programme.

Dealing with ‘brain drain’

Across most of sub-Saharan Africa, medical doctors are leaving their jobs for more lucrative work outside their countries. This ‘brain drain’ has resulted in non-physician clinicians increasingly taking on specialized or upper-level clinical functions, performing such vital procedures as surgery, work normally done by doctors. Midwives and nurse-midwives are also teaming up with the new health clinicians to provide more emergency obstetric and newborn care.

Task-shifting from doctors and other highly qualified personnel to health workers with less training and fewer qualifications aims to make more efficient use of the resources available in Ethiopia. Studies have shown that the surgical outcomes of properly trained and supported clinicians are comparable to those of doctors. Moreover, by performing the emergency interventions at rural health centres, the clinicians can help cut the cost of referrals to regional hospitals.

More than half of African countries have programmes that train non-physicians in integrated emergency surgery and obstetrics. In Malawi, Mozambique, Tanzania and Zambia, the programmes have shown such mid-level professionals are more likely to stay in their communities and countries than obstetricians, gynaecologists or general practitioners. In addition, the cost of training, deployment and salaries of these clinicians was much lower than for physicians, making it the best option for many African nations in reducing maternal deaths.

--Abraham Gelaw