Distributing Misoprostol in rural Ethiopia
Target 5 of the Millennium Development Goals stipulates that by 2015, the maternal mortality ratio be reduced by three quarters. In a country like Ethiopia, this is a daunting task. Women in labor face multiple obstacles including poor access to health care facilities, birth attendants with inadequate equipment, supplies, and training, and lack of knowledge about when to seek emergent medical care. One of the major contributors to maternal death in Ethiopia is post-partum hemorrhage. This can largely be prevented with an inexpensive drug called Misoprostol.
With a travel grant from the MGH Center for Global Health, I recently traveled to Ethiopia to help improve a program to distribute Misoprostol to health extension workers and traditional birth attendants in a southern district of Ethiopia called Shebedino. In the center of this district is the Leku Health Center. This small rural clinic provides maternal services including pre and post-natal care and emergency delivery services to a catchment area of approximately 600,000 people within about 1000 square miles. Over the past three years, Wide Horizons for Children (WHFC), an NGO based in Waltham MA, has administered this program. They have provided training to over 100 birth attendants and distributed over 1000 doses of the drug. To ensure the future success of this program, I was asked to re-evaluate the program and advise the staff on data collection and analysis.
Prior to my departure, I was concerned that it would be difficult to obtain data from the health extension workers. I couldn’t help but think that our request for data was going to be too onerous. It turned out I was wrong. The health extension workers and the staff at the Leku clinic are very adept at data collection. They compile monthly reports that include information on at least 30 different variables associated with maternal and infant health. With help from the clinic administrator and midwife, we were able to collect nine months of retrospective data for seven kebele (towns). I was very impressed with the level of organization and detail that went into collecting and compiling this data. The one piece that was missing was data analysis. With this in mind, I introduced a software program called Epi Info. This free program, offered by the CDC, provides tools for data collection, analysis, and visualization. Using this tool, the WHFC staff created a data collection form that works seamlessly with the monthly maternal data reports kept at the clinic. We then set up an analysis template, so that as each month’s data is entered into the program, graphs, charts, and statistics are automatically generated. This simple tool will enable the WHFC staff and the midwife at the clinic to visualize the impact of the Misoprostol program on this community.
The retrospective data indicated that not a single mother had died during delivery over the previous nine months. Certainly, this was good news; however, it suggested that the data was either inaccurate or incomplete. Misoprostol had not been widely distributed during this time and we were unaware of any other interventions going on in the community that could account for this 0% mortality. It was during a meeting with health extension workers and traditional birth attendants that we discovered the problem. They explained that the clinic data only included deliveries attended by a health extension worker. This represents about half of all deliveries in the community. Thankfully, the maternal and infant mortality data is also routinely collected for deliveries attended by traditional birth attendants; it just isn’t compiled at the clinic. We successfully negotiated a plan for the health extension workers to provide this additional data both retrospectively and prospectively to the clinic.
This trip was by far the most productive trip I have ever had to Ethiopia. I successfully met and even surpassed my goals and objectives. I was so impressed with everyone’s level of commitment and willingness to go above and beyond to make this program a success. It is clear that they are all very motivated to get Misoprostol distributed within this community. On a personal level, it was a delight to become better acquainted with the health extension workers, many of whom I had met on previous trips. My daughter was born in Leku. I saw her reflected in the faces of many of the young women I worked with. I am so grateful to have had this opportunity.