Benchmarking Progress in Ethiopia

In assessing neonatal and maternal mortality progress in Ethiopia, it is valuable to contextualize this progress in comparison to peer countries and international targets. Although lessons from Exemplar countries, including Ethiopia, are designed to provide insights for peer countries, Exemplar countries themselves can still benefit from cross-country comparisons. Positioning progress relative to other geographies provides insights into trajectories of mortality reduction, potential future challenges, and progressions towards global targets.

The maternal, neonatal, and stillbirth mortality transition framework

Multi-country comparison

Ethiopia has accomplished notable reductions in neonatal and maternal mortality, establishing the nation as an Exemplar. However, additional progress is needed to reach the Sustainable Development Goal (SDG) targets of 140 maternal deaths per 100,000 live births and 12 neonatal deaths per 1,000 live births by 2030

Ethiopia’s maternal mortality ratio (MMR) in 2020 was 267 maternal deaths per 100,000 live births, while its neonatal mortality rate (NMR) in 2021 was 26.2 neonatal deaths per 1,000 live births.^1,2 Although Ethiopia is an Exemplar in our study, findings from other Exemplar countries may still prove valuable in helping the country accelerate progress towards the SDG targets.

Learnings from a multi-country analysis, using an integrated maternal, neonatal, and stillbirth mortality transition framework, may prove useful as Ethiopia looks to further reduce MMR and NMR.³ In this framework, maternal and peri-neonatal (neonatal mortality including stillbirths) mortality are categorized into five phases, with phase I indicating higher mortality and phase V indicating lower mortality. The transition framework is a tool that can be used to benchmark country progress and chart a path to progress – with distinct drivers mapped to successive steps.

Stepwise trajectory to progress

From 2000 to 2020, Ethiopia progressed from phase I to phase III in the integrated maternal, neonatal, and stillbirth mortality transition framework. As Ethiopia nears phase III, the framework can yield insight into the characteristics that are usually observed as countries undergo mortality trends comparable to Ethiopia. This framework may also be useful in considering what factors as vulnerable to setbacks as a country or region experiences challenges and disruptions.

Through our multi-country analysis, we identified key factors that were associated with advances along this transition. Advancements beyond phase I were often linked to contraceptive use and fertility declines. Further progress through phase II and III often occurred as coverage of antenatal care, in-facility delivery, skilled birth attendance, and postnatal care improved, in part due to an expansion of physical infrastructure and human resources for health. This often led to a transition in causes of death in phase III, as preventable infections represent a shrinking portion of deaths, whereas indirect causes such as underlying maternal health conditions contribute a growing share of deaths. Finally, transitions to phase IV and V frequently reflect a prioritization of health equity, as vulnerable communities gain access to interventions previously only accessible to richer, more urban, or highly educated communities.

Ethiopia has seen a reduction in fertility and an expansion of health services driven by the Health Extension Program (HEP), contributing to progress from phase I to II. As the country continues to progress further through the transition, addressing equity gaps will be crucial for advancing to later phases and reducing mortality levels. The following sections of this report will highlight trends in health care equity.

Progressing toward the Sustainable Development Goals

Ethiopia has accomplished remarkable reductions in NMR and MMR in the past two decades. This progress has situated the country nearer to the SDG targets, although continued progress will be necessary to reach these ambitious targets.

The SDG target for maternal mortality is for global MMR to be less than 70 maternal deaths per 100,000 live births. Each country has a national target of a two-thirds reduction from 2010 levels of MMR by 2030, with no country’s MMR to exceed 140 maternal deaths per 100,000 live births. Given Ethiopia’s high baseline MMR, the country’s national SDG target is 140 maternal deaths per 100,000 live births. After experiencing a rapid average annual relative reduction (AARRs) in MMR from 2000 to 2020 of 6.17%, Ethiopia is almost exactly on-track to achieve the SDG target.² In order to achieve this target, Ethiopia would need to maintain or slightly accelerate progress to an AARR of 6.24% between 2020 and 2030.

For NMR, the SDG target is 12 neonatal deaths per 1,000 live births for all countries. Ethiopia must similarly accelerate progress to successfully reach this target by 2030. From 2000 to 2021, the country experienced an AARR of 2.89%, which will need to be accelerated to 8.31% to reach the SDG target by 2030.¹

Notably, these projections are based on trajectories of progress that generally predate a series of recent challenges that Ethiopia has faced – mostly notably including the COVID-19 pandemic and conflict in the Tigray region. As such, these forecasted scenarios may not fully be able to capture the realities of current obstacles to continued mortality declines.

Equity trends for key reproductive, maternal, newborn, and child health indicators in Ethiopia

Narrowing existing equity gaps in key indicators – including family planning, antenatal care coverage, in-facility delivery, cesarean section (C-section), and postnatal care – will be crucial in continuing Ethiopia’s rapid progression through the transition framework and achieving SDG targets. Considering Ethiopia’s widely diverse demographics across regions – especially with regards to pastoralist and agrarian settings – identifying subnational trends is particularly important in the country.

Family Planning

In 2000 in Ethiopia, family planning was generally only available to the most affluent communities, as demand satisfied by modern methods was 38.7% for the wealthiest quintile, but under 10% for all others.⁴ This resulted in an absolute gap in demand satisfied of 33.6% in 2000 between the richest and poorest wealth quintiles.⁴ This gap remained at 33.0% in 2016, but considering the low baselines in coverage for poorer wealth quintiles, this indicates greater relative progress for these communities.⁴ From 2000 to 2016 the poorest wealth quintile saw a 12.5% compound annual growth rate (CAGR) in demand satisfied by modern methods, which was almost three times faster than the 4.2% CAGR experienced among the wealthiest quintile over this period.⁴

As with many health service indicators in Ethiopia in recent decades, the equity gap between in urban and rural populations in terms of demand for family planning satisfied by modern methods narrowed dramatically. In 2000 there was a 39.0% absolute gap between urban and rural communities, and by 2016 this had shrunk to 12.9%.⁴

Demand satisfied varied dramatically by region in Ethiopia, with Addis Ababa and Amhara having the highest levels of coverage at 75.4% and 72.5% respectively in 2016.⁴ These relatively high levels of demand satisfied contrast with coverage levels in the region of Somali at 9.6%, which was by far the lowest of any region in Ethiopia.⁴

Antenatal care

Coverage of ANC has seen slightly different trends across equity dimensions. While the CAGR for ANC4+ coverage has been higher among the poorest wealth quintile than the richest quintile, this margin has not been high enough to narrow the gap in the past two decades. In 2000, there was a 30.6% absolute gap in ANC4+ coverage between the wealthiest and poorest quintiles, but by 2019 this had expanded to a 50.3% absolute gap.⁴ This translates to 70.4% of mothers in the wealthiest quintile receiving four or more antenatal care visits compared with only 20.1% of mothers in the poorest wealth quintile.⁴

Despite this trend, equity gaps narrowed between urban and rural communities. In 2000, there was an absolute gap in ANC4+ coverage of 37.6% between urban and rural populations, but this decreased to 21.3% by 2019.⁴ This indicates that in 2000, mothers in urban areas were 7.2 times more likely to receive four antenatal care visits as compared with mothers in rural areas, whereas in 2019 mothers in urban areas were only 1.6 times more likely to receive four or more antenatal care visits as compared to mothers in rural areas.⁴

As with family planning, there have been large regional disparities within Ethiopia in antenatal care coverage. The urban regions of Addis Ababa and Dire Dawa had high ANC4+ coverage levels in 2019 at 81.6% and 62.6% respectively.⁴ The region of Tigray also stood out with high ANC4+ coverage at 65.0% in comparison to other, similarly large regions.⁴ In contrast, the regions of Somali and Gambela had lower ANC4+ coverage levels, respectively at 11.4% and 24.2%⁴

In-facility delivery

In Ethiopia in 2000, facility-based delivery was almost entirely limited to the wealthiest communities. In-facility delivery rates were 22.7% among the wealthiest quintile, 3.2% for the second wealthiest quintile, and near 1% for the poorest three quintiles.⁴ There have been dramatic improvements for in-facility delivery coverage in recent decades, though disparities across wealth quintiles have expanded. In 2019, in-facility delivery coverage was 85.9% among the wealthiest quintile and 19.7% among the poorest quintile.⁴ The absolute gap between the richest and poorest quintiles has therefore expanded from 22.0% in 2000 and 66.2% in 2019.⁴

Contrastingly, the in-facility delivery coverage gap between urban and rural populations has stayed relatively constant. In 2000 there was a 29.6% absolute gap between urban and rural communities for in-facility delivery coverage, which increased slightly to 30.4% in 2019.⁴ The in-facility delivery rate among rural communities more than doubled in the brief span from 2016 to 2019, increasing from 19.7% to 40.0%⁴

Regional trends for in-facility delivery mirror regional trends for other health indicators, with Addis Ababa seeing the highest coverage level in 2019 at 96.5%.⁴ The regions of Gambela, Tigray, and Dire Dawa also have high rates of in-facility delivery at 76.1%, 75.4%, and 74.6% respectively.⁴ The regions of Somali and Afar have the lowest levels of in-facility delivery, with coverage at 27.2% and 34.7% respectively.⁴

Cesarean section

Disparities in in-facility delivery coverage has translated to gaps in C-section rates across many equity gradients, with this procedure being far more common among wealthier, urban communities. In 2000 almost all C-sections occurred among births for the wealthiest quintile, as 3.6% of births to the wealthiest women were via C-section wereas less than 0.2% of other births were by C-section.⁴ In 2019, this procedure still occurred substantially more frequently among wealthier women than poorer women, accounting for 14.3% of births among the wealthiest quintile and 1.6% among the poorest.⁴

The gap in C-section rates between urban and rural communities expanded from 4.9% to 6.2% from 2000 to 2019.⁴ There was substantial progress among rural populations between 2016 and 2019, with the C-section rate increasing by more than four times in this brief time span.⁴

Regional trends in C-section rate reflect urban and rural disparities, as Addis Ababa and Dire Dawa stand out as regions with particularly high C-section rates at 24.3% and 18.7% respectively.⁴ According to the World Health Organization, C-section rates that exceed 10% are not associated with additional benefits to reducing MMR, indicating that the C-section rates in these localities may be excessive.⁵ In contrast, C-section rates in the regions of Somali and Afar were substantially lower, at 1.1% and 2.7% respectively.⁴

Postnatal Care

In line with other health service indicators, disparities in postnatal care (PNC) coverage levels have similarly improved. This is likely linked to trends seen for in-facility delivery across wealth quintiles. In 2019, 50.7% of mothers in the wealthiest quintile received PNC within four hours of birth as compared with only 11.3% of mothers in the poorest quintile.⁴ This absolute gap of 39.4% is larger than the 17.5% absolute gap seen in 2011.⁴ In 2011, less than 1% of mothers in the poorest quintile received PNC within four hours of birth.⁴ Levels of neonatal care in the first hour of life have greatly improved across all wealth quintiles, but they have improved most rapidly for children born to wealthier women. In 2019, 41.5% of babies born to women in the wealthiest quintile received neonatal care in the first hour of life as compared to 8.4% of babies born to women in the poorest quintile.⁴

Equity gaps between urban and rural communities have not seen comparable trends, and have stayed similar to past levels or narrowed. In 2019 the absolute gap in maternal PNC within four hours of birth was 14%, which marks an improvement from 20.6% in 2011.⁴ The gap for neonatal care within the first hour of life has experienced only modest widening from 7.7% in 2016 to 9.9% in 2019.⁴

Addis Ababa had the highest rates of PNC, with 65.1% of newborns receiving neonatal care within the first hour of life and 63.2% of mothers receiving PNC within four hours of birth. Tigray and Gambela also had high coverage levels, although they performed slightly better for maternal PNC than for neonatal care. The regions of Somali and Afar had the lowest levels of PNC, with 8.5% and 19.8% of mothers receiving PNC within four hours of birth while 7.9% and 16.7% of neonates received care in the first hour of life, respectively.⁴