What Did Ethiopia Do?

Improvements in reproductive, maternal, newborn and child health indicators

Contraception access

Ethiopia has seen a rapid rise in the percentage of women utilizing modern methods of contraception. In DHS 2019, 40.5% of married women were using a modern method of contraception, whereas in DHS 2000 only 6.3% were.¹ In this assessment as well as in further evidence from DHS, the values presented refer to the years immediately preceding the survey which were included within the questionnaire’s study window. In DHS 2019, the most prevalent forms of modern contraceptives were injections and implants, which respectively constituted 67.2% and 21.0% of modern contraceptive use among married women.¹ This has translated to an increase in the demand for family planning satisfied by modern methods, which increased from 14.2% to 60.6% between 2000 and 2016.¹

Increasing contraception access and uptake were key goals of the National Reproductive Health Strategy (2006-2015 & 2016-2020) which contributed to the rapid acceleration of contraception progress in Ethiopia.^1,2,3 The vast majority of all contraception was provided by public facilities in Ethiopia, often at lower level health facilities.¹ One study in the West Gojjam zone within the Amhara region identified that higher levels of contraception access were seen in households with higher engagement in the Health Extension Program (HEP) – specifically through packages meant to educate community members about the benefits of contraception and the variety of contraceptive methods.⁴ Mothers in families that had completed 75% of HEP packages were 3.97 times more likely to use contraceptives than those who had not, with 93% of women reporting that they received information about family planning from health extension workers (HEWs) through the HEP.⁴ Another study in the Tigray region similarly found that HEWs were the primary source of information on long-acting contraceptive methods.⁵

As contraception use has become more common in recent years, the fertility rate in Ethiopia has declined from 5.5 to 4.1 births per woman from 2000 to 2019.¹ Age-specific fertility rate declined across all age groups, most notably among women aged 30 to 34 where there has been a reduction of 81 births per 1,000 women over two decades.¹ Births among women ages 15 to 19 and 20 to 24 also declined by 28% and 17% from 2000 to 2019. This reflects a slight increases of age at first marriage in Ethiopia, which rose from a median age of 16.4 to 17.5 years between 2000 and 2016.¹

Antenatal care coverage

Pregnant women in Ethiopia have increasingly received antenatal care (ANC), with the percentage of women receiving at least four ANC visits increasing from 9.2% to 43.0% from 2000 to 2019.¹ Similarly, the percentage of women receiving at least one ANC visit grew from 25.8% to 73.9% over this time span.¹ This ANC generally began earlier in pregnancies, with 26.9% of women receiving care in the first four months of pregnancy in 2019 as compared to 5.1% in 2000.¹

The vast majority of this ANC was provided by nurse/midwives, reflecting the proliferation of this class of health workers in the Ethiopian healthcare system since the establishment of the Health Extension Program.¹ Increases in ANC coverage were also mainly driven by increases in services given to pregnant women living in rural areas and in lower income homes. One study in districts within the Southern Nations, Nationalities, and Peoples (SNNP) and Tigray regions found that women visited by HEWs at least once during pregnancy were 3.46 times more likely to attend four or more ANC consultations.⁶ Another assessment in Amhara, Oromia, SNNP, and Tigray identified that areas with a higher density of Health Development Army (HDA) leaders were associated with higher ANC coverage for the households in the surrounding community, with local HDA leaders having a positive influence on the effectiveness of HEWs.⁷

Antenatal care quality

In parallel with the expansion of access and uptake of ANC, evidence also shows that the quality of ANC services has improved. Of women who received ANC in 2019, 80.9% had a blood sample taken and 75.8% had a urine sample taken whereas in 2000 only 24.6% and 20.1% of women respectively reported these samples being collected.¹ Similarly, the percentage of mothers who received iron supplementation before birth increased from 10.2% in 2005 to 59.3% in 2019.¹ Provider communication with mothers has improved as the rate of women being informed about signs of pregnancy complications nearly doubled from 23.9% to 45.5% between 2000 and 2016.¹

In-facility delivery

From 2000 to 2019 the rate of in-facility delivery in Ethiopia increased from 4.9% to 53.9%.¹ This increase was primarily driven by increased births at public facilities, with over 95% of facility-based deliveries in 2019 occurring there.¹ In 2000, 2.6% of births occurred in lower-level facilities and by 2019 this number had risen to 35.4%.¹

In 2019, 13.9% of women who had received no ANC delivered in facilities where as in 2000, only 1.8% of women who had received no ANC delivered in facilities.¹ In-facility delivery rates have increased dramatically specifically among women who received at least four ANC visits, growing from 26.7% in 2000 to 77.3% in 2019.¹ Evidence suggests that in-facility delivery rates are higher among younger mothers, as 53.6% of women younger than 20 gave birth in a facility in 2019, compared to 47.8% of mothers aged 20-34 and 39.7% of mothers aged 35-49.¹ Compared with other health services such as family planning and antenatal care, evidence is less robust that engagement with HEWs promotes in-facility delivery – with some studies suggesting that this may stem from less confidence among mothers in the ability of HEWs to perform or assist with delivery care.^8,9 Maternity waiting homes have also played a role in improving in-facility delivery rates, providing a place for mothers to stay in the days before giving birth. Ethiopia has expanded the number of maternity waiting homes, which evidence suggests has been particularly utilized by rural communities that would have long travel times to facilities.¹⁰

Skilled birth attendants

From 2000 to 2019, the percentage of deliveries in Ethiopia attended by skilled providers grew from 5.6% to 55.8%.¹ This increase in delivery by a skilled birth attendant represents a shift from deliveries being mostly provided by relatives/other (55.4%) and nurses/midwives (7.7%) in 2011, to 5.5% of deliveries being provided by a relative/other to 39.6% by nurses/midwives in 2019.¹ The proportion of deliveries attended by doctors also saw increases, growing from 2.0% in 2011 to 6.5% in 2019.

Due to a shortage of physicians, Ethiopia developed an innovative approach of training nonphysician providers – primarily health officers and nurses with Bachelors of Science degrees who had worked in facilities for more than two years – to perform emergency surgery, including C-section.¹¹ Non-physician surgical providers, called Integrated Emergency Surgical Officers (IESOs), were introduced to improve access to C-sections in rural areas, a critical task shift that increases access to the procedure. Created in 2009, the IESOs cadre undergo a three-year course in emergency obstetrics and general surgery and by 2014, this cadre represented 1 per 100,000.¹¹ By 2016, most hospitals provided C-section services, and the creation of IESOs has made skilled birth attendants increasingly skilled at providing more complex forms of delivery care, with C-section one of the most common surgeries performed by this class of providers.¹¹

Cesarean section rates

The C-section rate in Ethiopia increased from 0.6% to 6.5% of all births from 2000 to 2019.¹ Of births occurring in facilities, the C-section rate in the 2019 survey was 10.8% in public facilities and 42.2% in private facilities – though only 2.4% of births nationally took place in private facilities.¹

According to Service and Provision Assessment (SPA) surveys on facility readiness, in 2014 84% of referral hospitals, 86% of general hospitals, and 77% of primary hospitals offered C-section and by 2022, these values had increased to 94%, 95%, and 88% respectively.^12,13 The establishment of a cadre of workers called Integrated Emergency Surgical Officers (IESOs) has contributed to the increasing ability of facilities to offer C-section, despite a lower density of physicians. Referrals to more hospitals have also been facilitated by the establishment of maternity waiting homes, which may house women from rural areas who have experienced pregnancy warning signs before undergoing a C-section at a hospital. Although the availability of C-section services has increased, high out of pocket costs are still of some concern, with C-sections often being relatively costly procedures. Community-based health insurance schemes have been established that have been found to mitigate these costs, though challenges persist to ensure all populations do not face financial barriers to care such as C-section.¹⁴ C-section rates in Ethiopia remain lower than peer countries in East Africa such as Kenya and Tanzania, which respectively had C-section rates of 16.5% and 10.8% in DHS surveys from 2022.¹

Maternal postnatal and neonatal care

Coverage of postnatal care (PNC) for mothers in the first two days after birth increased dramatically in Ethiopia from 6.7% in 2011 to 33.8% 2019.¹ PNC shortly after delivery also increased as 3.9% of mothers received care within four hours of birth in 2011 compared with 29.1% in 2019.¹

Similarly, PNC for newborns within the first two days after birth increased from 0.3% in 2011 to 34.5% in 2019.¹ This care occurred within the first hour of life for 23.9% of newborns in 2019, an increase from 0.0% in 2011.¹ Data on the contents of PNC are limited to recent years, but improvements are detectable in the small span between 2016 and 2019. In this three-year interval, cord examination increased from 10.2% to 26.4% of births, temperature measurement improved from 13.7% to 25.8% of births, and counseling on danger signs rose from 11.6% to 21.1% of births.¹

Evidence suggests that increased rates of postnatal care are associated with deeper engagement with HEWs and the Health Extension Program. Once study found that women visited by a HEW during pregnancy were 3.68 times more likely to receive postnatal care within three days of delivery.⁶

Connecting reproductive, maternal, newborn and child health indicators to mortality reductions

The rapid reduction in neonatal and maternal mortality seen in Ethiopia is driven by interconnected distal, intermediate, and proximal factors. Distal factors reflect “upstream” social, political, and economic influences. Intermediate factors include programs and services that influence people’s ability to access high-quality health care as well as household and individual contextual factors that influence health-seeking behavior. Proximal factors include variables immediately relevant to the point of care, playing more direct roles in influencing health outcomes.

Three quantitative assessments were conducted to provide insight into how these factors influence neonatal and maternal mortality. First, a decomposition analysis was conducted to specifically assess the contribution of fertility decline on mortality reduction. To assess the contributions of specific interventions, an analysis was also conducted using the Lives Saved Tool, allowing for a more detailed look into intermediate and proximal. This was further complemented by a hierarchical decomposition analysis that was also able to incorporate evidence from more distal factors. These approaches work in concert to describe factors that contributed to Ethiopia’s decline in neonatal and maternal mortality.

Fertility decline as a contributor to NMR/MMR improvements

There have been notable decreases in fertility in Ethiopia in recent decades, as total fertility rate decreased from 5.5 to 4.1 births per woman from 2000 to 2019.¹ Declines in fertility translate to fewer high-risk pregnancies by way of longer birth intervals, lower birth parity, and decreased birth rates especially among teen girls and older women.

Our analysis, using Jain’s decomposition method,¹⁵ isolates the impact of fertility decline on maternal and neonatal mortality. Fertility decline alone in Ethiopia was found to explain 26% of the MMR reduction and 29% of the NMR reduction between 2000 and 2017. These mortality reductions translate to 4,951 maternal fewer maternal deaths in 2017 and 39,388 fewer neonatal deaths in 2019 than would have been expected if fertility levels had remained constant since 2000. This decomposition approach attributes other improvements to ‘safe motherhood’ initiatives, a term used to collectively refer to improving intervention coverage and services such as antenatal care, in-facility delivery, skilled birth attendance, and emergency care services. Together, fertility decline and improved safe motherhood initiative coverage led to 34,676 additional maternal lives saved in 2017 and 142,476 additional neonatal lives saved in 2019, compared with what would have been expected if fertility rate and coverage levels had remained constant since 2000. This result, shown in Figure 16, highlights the impact of fertility decline as a key driver of MMR and NMR decline, in tandem with other health care indicators commonly associated with MMR and NMR decreases.

Lives saved by intervention analysis

An analysis using the Lives Saved Tool was conducted, incorporating 17 maternal interventions and 21 neonatal interventions that were found to save lives as these interventions’ coverage improved from 2000 to 2020. The Lives Saved Tool uses estimates of intervention coverage, effectiveness of interventions, and estimates of NMR and MMR to model the contribution of each intervention to mortality reductions.¹⁶

Of the maternal lives saved that were explained in this analysis from 2000 to 2020, almost half, 46.7%, were attributed to improvements in contraception use. Most of the remaining explained maternal lives saved were attributed to interventions occurring during childbirth, which collectively accounted for 48.9% of maternal lives saved. The largest contributors in this category were uterotonics, magnesium sulfate, and parenteral antibiotics which respectively explained 10,388, 6,684, and 5,755 maternal lives saved cumulatively from 2000 to 2020.

Of the neonatal lives saved that were explained in this analysis from 2000 to 2020, about a quarter, 26.0%, were attributed to increased tetanus toxoid vaccination. Improvements in case management of sepsis/pneumonia were the second most notable takeaway, accounting for 5,760 additional neonatal lives saved cumulatively from 2000 to 2020. The next nine most impactful interventions identified in this analysis were all considered interventions that occurred at the moment of birth, which collectively accounted for 58.0% of all explained neonatal lives saved. The most notable of these were C-section, neonatal resuscitation, and clean cord care which respectively saved 4,304, 5,567, and 5,068 additional lives in 2020 based on improved coverage levels than would have been expected based on 2000 coverage levels.

Hierarchical neonatal mortality decomposition analysis

Using these distinct categories, a multivariable hierarchical decomposition analysis was conducted for the period 2000 to 2019 in Ethiopia. Through this analysis, we aimed to produce findings that could yield more granular insights than the fertility-based Jain’s decomposition analysis presented earlier, while also reflecting the influence of broader factors that cannot be captured in an intervention-based Lives Saved Tool analysis. This approach was only conducted for NMR—and not MMR—due to the relative rarity of maternal mortality compared with neonatal mortality, resulting in scarce individual-level MMR data. Included variables do not represent a comprehensive range of factors that drove progress over the last two decades in Ethiopia – and in some instances may signal the influence of related factors – but this analysis nonetheless provides valuable insight to the relative impact of several key components of progress in the country.

In this analysis, two proximal drivers were identified as key contributors to NMR reduction in Ethiopia. ANC4+ (at least four antenatal care visits) increased from 10.6% in 2000 to 43.3% in 2019 and was found to explain 19.1% of the observed NMR decline.¹ While C-section rates slightly increased in Ethiopia over this time span, a more pronounced increase among the wealthiest two quintiles was identified through this analysis – growing from 1.8% in 2000 to 11.6% in 2019.¹ Increased C-section rate specifically among this demographic was therefore found to account for 14.8% of the observed NMR reduction.

The intermediate factors of improved sanitation and enhanced ANC quality were also identified as main contributors to Ethiopia’s NMR reduction, respectively explaining 22.6% and 19.9% of the NMR decline. From 2000 to 2019, the percent of households that were found to have an improved toilet grew from 7.7% to 56.5%.¹ ANC quality also saw remarkable progress, here captured by the percent of women who reported having their blood pressure during their visit, which rose from 43.2% in 2000 to 98.5% in 2019.¹ Other intermediate factors such as evolving risk profiles of mothers were also found to play a smaller role in influencing Ethiopia’s NMR reduction, with maternal age, birth parity, and marital status signaling slight changes over time.

Two distal factors also emerged through this analysis as key factors that account for portions of Ethiopia’s progress. A reduction in poverty levels – which decreased from 49.9% in 2000 to 24.8% in 2019 – explained 8.0% of the NMR reduction.¹ Similarly, electricity access accounted for 7.1% of Ethiopia’s NMR progress, with 27.5% of households having electricity compared to 7.5% in 2000.¹