NEONATAL AND MATERNAL MORTALITY REDUCTION IN Ethiopia
Ethiopia has achieved particularly notable reductions in maternal mortality, made possible through deep engagement with communities that drove demand for services as the health system grew.
Contents
Introduction to Ethiopia
Located in East Africa, Ethiopia is the second most populous country on the African continent. According to UN estimates, the country was home to 123 million people in 2022, and is characterized by its diversity in terms of language, religion, ethnicity, and lifestyle.1 The country includes one of Africa’s largest cities, Addis Ababa, which serves as the headquarters of the African Union and other international organizations. This hub of over 5 million people presents a starkly different environment than the rural regions of Ethiopia, which have large pastoralist populations that are generally mobile.2 Ethiopia over the years has made remarkable efforts to expand its health infrastructure and workforce into rural areas – where almost 80% of its population lives.3 It has thus achieved success across many indicators, as also seen in the under-five mortality reduction, community health workers and stunting reduction Exemplar studies.
As of the completion of this study, Ethiopia is divided into twelve regions and two city administrations – Addis Ababa and Dire Dawa. Regions are further divided into zones, woredas (districts), kebeles in rural areas, as well as municipalities in urban areas. These regions vary in size and population, with the large regions of Oromia and Amhara alone consisting of over half the country’s population as highlighted in Figure 1. In contrast, smaller regions such as Gambela and Harari have populations below half a million. This wide range in size is because regions have been generally classified on the ethnicity and language of local populations.
Figure 1: Population Density by Administrative Region of Ethiopia, 2000 and 2020
Ethiopia has seen enormous economic growth in recent decades, with gross domestic product per capita increasing from US $259 to US $835 (2015 US dollars) from 2000 to 2021.4 This reflects a 222% relative increase in gross domestic product per capita over that span, the largest growth seen for any African nation.4 In line with this economic advancement, the percentage of people in Ethiopia living in poverty (i.e., living on less than US$2.15 per person per day) decreased from 29.3% in 2000 to 8.5% in 2019.5
While this economic progress is remarkable, our country selection analysis found that it does not entirely explain Ethiopia’s progress in reducing neonatal and maternal mortality in recent decades. Additional details about Ethiopia are included in the Context section. The majority of this narrative will highlight key indicators, interventions, policies, and programs that contributed to rapid neonatal and maternal mortality reductions in Ethiopia over the period of 2000 to 2020.
Key Insights
Ethiopia has prioritized expanding access to health services, largely focused on maternal, newborn, and child health, especially in rural communities. The country’s health extension program has substantially improved linkages between communities and the health system.
Designed primary health care around the community
Ethiopia expanded access to care in rural areas by organizing primary health care through the Health Extension Program.
Ethiopia launched the Health Extension Program (HEP) in 2003, which includes 18 health packages rooted in health promotion, prevention, and basic curative services. HEP initially begun in the four larger agrarian regions, then later expanded to pastoralist communities in 2006, and to urban centers in 2009. Health Extension Workers (HEWs) are crucial components of this program: salaried government employees with a year of training who are assigned to health posts and spend ~75% of their time visiting households. Community engagement is further facilitated by women-led community organizations called the Health Development Army. The HEP has dramatically expanded access to essential health services in rural areas, reflected in increased health utilization since the program’s launch.
Mitigating barriers to delivery care
Ethiopia launched ambulances and maternity waiting homes to increase access to delivery care in facilities for women in rural areas.
With lack of transportation as a major barrier to care, Ethiopia enacted a national plan in 2012 to distribute a four-wheeled ambulance in each rural district in the country. Ambulances were made free to women and reachable via telephone, with a total of 1,250 ambulances introduced across the country. Ethiopia also scaled up maternity waiting homes (MWHs), with 56% of health centers and 18% of hospitals having MWHs by 2016. MWHs are free temporary residences next to health facilities that house women from remote areas in their last weeks of pregnancy. MWHs enable access to timely obstetric care at the onset of labor, helping to reduce the risk of obstetric complications and perinatal mortality.
Upskilled providers to deliver emergency care
Ethiopia launched and rapidly scaled a new cadre of healthcare workers by training mid-level providers to perform emergency obstetric surgeries.
The Ethiopian MoH created the Integrated Emergency Surgery and Obstetrics (IESO) cadre in 2009, which rapidly trained non-physician surgical providers in emergency obstetrics and general surgery. This program enabled task-shifting to improve access to C-section in rural areas with shortages of healthcare professionals in surgical training. The government launched accelerated training programs that resulted in increased availability of these cadres in a short time, with 1 IESO provider per 100,000 population by the end of 2014. Since the introduction of this cadre, the number of maternal and neonatal lives saved due to C-section has increased greatly. Our quantitative analysis found that increasing rates of C-section also accounted for 14.8% of the observed decline in neonatal mortality rates between 2000 to 2019.
Contextualizing Ethiopia’s Progress in an Integrated Mortality Transition Framework
Ethiopia moved from phase I in 2000 to phase III in 2020 on the transition framework, demonstrating exemplary progress in improving maternal and neonatal health outcomes.
Ethiopia advanced rapidly through the phases of the integrated mortality transition framework over the past two decades. Assessing this trajectory of progress in the context of the transition framework allows for insights about what Ethiopia may need to prioritize in the future to sustain the progress it has experienced in recent decades.
Exemplars in Global Health program
The Exemplars in Global Health program aims to learn from countries that have made rapid progress in improving health outcomes and disseminate this evidence to inform health policy and funding decisions. Our aim is to research success stories from low- and middle-income countries and share findings that can be useful for leaders looking to act in comparable contexts.
In selecting Exemplar countries, we review evidence to identify countries that outperformed their peers in vital areas of public health, controlling for factors such as economic growth. In this way, we aim to provide more actionable, policy-relevant insight for stakeholders about how health progress can be made despite resource limitations.
Together with research partners and technical advisers, we conduct quantitative and qualitative analyses to validate our initial assessments and assess factors that contribute to a country’s exemplary performance.
Research in and across Exemplar countries could help ministries, nongovernmental organizations, and multinational bodies better deploy finite resources to address key public health issues in low- and middle-income countries.
By studying proven strategies to prevent disease, malnutrition, and other conditions that burden populations of low- and middle-income countries, we aim to create a list of data-driven narratives that can serve as resources for leaders looking to improve health within their own countries. The following narrative focuses on factors that contributed to rapid reductions in neonatal and maternal mortality in the Exemplar country of Ethiopia.
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1
World Bank. Population, total [data set]. Accessed June 6, 2023. https://data.worldbank.org/indicator/SP.POP.TOTL
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2
World Bank. Population in largest city [data set]. Accessed June 6, 2023. https://data.worldbank.org/indicator/EN.URB.LCTY
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3
World Bank. Rural Population (% of total population) [data set]. Accessed June 6, 2023. https://data.worldbank.org/indicator/SP.RUR.TOTL.ZS
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4
World Bank. GDP per capita (constant 2015 US$) [data set]. Accessed June 6, 2023. https://data.worldbank.org/indicator/NY.GDP.PCAP.KD
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5
World Bank. Poverty headcount ratio at $2.15 per day (2017 PPP) (% of population) [data set]. Accessed November 29, 2022. https://data.worldbank.org/indicator/SI.POV.DDAY
NEONATAL AND MATERNAL MORTALITY REDUCTION IN Ethiopia
