By Kate Klein
In Ethiopia, the prevalence of HIV, at 1.4 percent, is not high compared to other countries in sub-Saharan Africa. Some attribute this to the tight borders Ethiopia keeps from neighbors Eritrea, Sudan, Somalia, and particularly Kenya, whose prevalence is much higher, at 6.3 percent. The widespread practice of the conservative Ethiopian Orthodox religion, which advocates strong commitment to marriage and faithfulness, may also help explain the low figure. Finally, there is the recent fiscal dedication of the Ethiopia government toward improving healthcare infrastructure. It may be for these reasons and more that Ethiopia is one of only seven countries that have halved their HIV prevalence since 2009.
Despite these facts, there is still one fast avenue for transmission—from mother to child, or vertical transmission. Much of the reason for this high rate of vertical transmission can be traced to another public health problem: only 10 percent of all pregnant women in Ethiopia give birth in a health center. Those who do reside mainly in the cities, of which there are few in Ethiopia. With 90 percent of women giving birth at home, we also see high rates of maternal mortality (676/100,000) and under-five child mortality (88/1,000). Despite years of fighting this problem, the rates have not gotten better.
In recent years the Ethiopian government has begun efforts to address this and other public health problems. They are one of the few countries to meet the Millennium Development Goal of devoting 16 percent of their budget to health care. The Ministry of Health began, about three years ago, to rapidly increase the number of health centers and health posts across the country. The health centers serve as places for uncomplicated medical care and health posts serve as sites for outreach and education activities. One of the main problems, as the government saw it, was that women did not have access to health centers and that was why they gave birth at home. They then made antenatal care (ANC), delivery, and post-natal services free to all women: the “if you build it, they will come” theory. Unfortunately, every health center is meant to serve a catchment population of 25,000 people, and many people live as much as five hours away from these centers by foot. The roads are often drivable only by 4×4 cars, yet people rarely own cars there, and there is generally only one ambulance—which is often out of fuel and can take hours to arrive.
One of the only other options for women is to take a “human ambulance,” which consists of about six men carrying a stretcher to the hospital. Unfortunately, this can also take hours and women fear looking weak to their community. Indeed, fear of appearing weak to others is just one of the many cultural barriers to giving birth at the health center; these factors are just as important as infrastructural barriers. In different regions of Ethiopia there are different cultural barriers, but I will list just a few of the most common. As mentioned, to be thought of as a strong woman is an important trait. For pregnant women, showing weakness by making pained sounds during labor or delivery is shameful. It seemed very odd to me to enter delivery rooms in which all of the women were completely silent. Indeed, even going to the health center before labor is in the final stages is considered weak. The problem becomes that if you wait until labor is strong, it is too late to make it to the health center for fear of delivering on the way.
Another barrier comes from the family, particularly the mother-in-law. There is a long tradition of using traditional birth attendants or family members to attend to birth. There can be strong pressure from the family to deliver at home. They feel this way because they themselves delivered at home and see no problem with it. There is also the belief that by giving birth at home the baby truly belongs to the family. If they give birth somewhere else the baby has no home. Indeed, it is customary in some parts of Ethiopia to bury the placenta behind the house but at the health center they are not allowed to take the placenta with them. Finally, in this deeply religious country, there is the belief that Saint Mary is not in the health center, but only in the home watching over the birth. Therefore by giving birth in the health center mothers fear that the birth will not be blessed.
Of course, there are other barriers that fall somewhere between infrastructure and culture. Women complain that the health centers are poorly heated. Built out of concrete with no heaters, the health centers located in the highlands can get very cold. Another complaint is that there is no privacy or waiting room during labor. Indeed, most delivery rooms have only two delivery couches, which are in an open room with no space to wait while they are in labor. In fact, in Ethiopia many women prefer to deliver in a squatting position, which is impossible at the health center. Furthermore, it is common for the family of the woman to prepare a coffee ceremony and some porridge both before and after the birth. In the health center there is no food or water and many times the family is not allowed to be with the woman giving birth. Lastly, women are only allowed to stay about six hours after birth, or ten hours if there is complication. At this point transportation issues come into play.
Adding HIV infection into the equation complicates all of the above. On average, 71 percent of women do not use any form of contraception, so pregnancy in HIV-positive women is common. The Ministry of Health, USAID, and numerous international and local NGOs are working to reach these women early, as prompt treatment with ART prophylaxis, skilled delivery, and treatment of the infant within the first 45 days of life can make an incredible difference in stopping vertical transmission. In recent years, the Ministry of Health has opened five health posts for every health center. Each health post employs two health extension workers who are trained in about sixteen health topics and whose job is to go home to home in their community tracking pregnant women, among other health issues. They encourage women to visit the nearest health center for at least one ANC visit. The Ministry of Health has also begun to organize volunteer groups (led by traditional birth attendants and other influential female leaders) called the Women Development Army, who also go home to home educating residents on women’s health issues. Additionally, community and religious leaders are also recruited to reach out to women and their partners. All of these people are given color-coded referral cards instructing these women to go to the health center. Once turned in at the health center, these cards are used to track the most successful avenues through which these women are reached.
At her first ANC visit, each pregnant woman is tested for HIV, unless she chooses to opt-out. If she tests positive, she is immediately put on ARV combination therapy. She is also given a referral card for her partner, asking him to come with his wife to the next ANC visit, though not mentioning HIV or that she tested positive. She is added to a wall tracking chart, which lists by anonymous number all of the HIV-positive women at the health center and tracks their visits through delivery. Lastly, she is connected with a Mother Support Group at the health center or in the community.
Mother support groups are led by two HIV-positive “Mentor Mothers” who are responsible for making sure all the members stay with the program for 52 weeks, or long enough for them to give birth and for their newborn children to have confirmatory HIV testing. The program addresses the psychological and social needs of the mothers. It also teaches them what they need to know about living with HIV and preventing transmission to their children. During their time as members of the group, the women are given lessons on different topics related to their phase of pregnancy or lactation. They also learn about adherence to ARTs, dual protection with their partners, nutrition and exclusive breast-feeding followed by mixed feeding. The program, based on a Mother2Mother model developed in South Africa, has been wildly successful. The women look up to their Mentor Mothers as examples of how to live successfully with HIV. Almost 95 percent of mothers deliver HIV-negative babies, and even after graduating from the program they often become involved in other community associations to create awareness about HIV.
The Ministry of Health is working to address the infrastructural issues as well. Since building the health centers, the Ministry has worked to provide blankets and beds where women can come to sleep the week of their expected delivery date. The Ministry has also supplied delivery room equipment, heaters, and ingredients for porridge and for the coffee ceremony. They have also received donations of “mama kits” from UNICEF, which contain a blanket, a knit cap, and two bars of soap for every mother.
Of course there are challenges with all of these efforts. Tracking mothers and babies can be onerous for health center staff. The quality of the data can be difficult to ensure. Data such as partner testing can be especially dubious when health center workers are merely taking the word of the pregnant woman that her partner was tested and is HIV-negative. Other issues such as staff turnover also have a huge effect on quality of care. When health center staff are assigned to remote areas, there is a high chance that they will want to transfer somewhere else at the first opportunity. With turnover comes gaps in training and inconsistency in care. Finally, fluctuations in the health budget present additional problems. Since health centers do not make money on any services for pregnant women they can be hit hard if they are not making money elsewhere, particularly if the number of pregnant women they serve increases. When the health center lacks money, drugs will not be purchased, ambulances will not have fuel, and staff cannot be hired.
The NGOs and the Ministry of Health are working to address these problems by consistently training health care workers to ensure that they are fully capable to counsel, test, treat and track all of the people in their catchment area. On a quarterly basis, health care workers are given refresher trainings and are evaluated through a joint supportive supervision mechanism. This involves the NGO, a representative from the district health office, and the health center manager going to each health center to examine the rooms and supplies, and giving hypothetical scenarios to the health care workers to assess their knowledge of correct procedure. At the end of the day all three offices sign off on the evaluation after discussing areas for improvement, who is responsible for them, and the date that those areas will be corrected.
Though we will not truly know whether all of these efforts to reduce vertical transmission and maternal and child mortality are working until the next demographic and health survey comes out in 2016, the signs are positive. By working on a small scale to ensure HIV-positive pregnant women are not lost to follow-up and that health care workers have the capacity to treat them, as well as on a large scale to ensure adequate infrastructure is available, the Ministry of Health aims to change the behavior of pregnant women in Ethiopia. If they are successful, the hope is that the prevalence of HIV will be reduced to that of many developed countries across the world.
The opinions expressed in this article are the author’s alone and are not meant to represent those of any agency mentioned within. However, this research and the work described to protect child survival, to end maternal deaths and birth injuries, and to prevent the transmission of from mother to child of HIV is made possible by the US Agency for International Development (USAID) and the President’s Emergency Program for AIDS Relief (PEPFAR). Thanks go to IntraHealth International for the opportunity to serve as an intern on their CPMTCT Project.
- No formal research has been done to substantiate these hypotheses explaining this reduced prevalence. The possible explanations listed here are merely the general observations of various health professionals with whom the author spoke.
- “Ethiopia Demographic and Health Survey 2011,” Central Statistical Agency (Addis Ababa, Ethiopia and Calverton, Maryland, USA: ICF International, March 2012). http://measuredhs.com/pubs/pdf/FR255/FR255.pdf
- “Health Financing: Health Expenditure Ratios by Country,” Global Health Observatory Data Repository, World Health Organization. http://apps.who.int/gho/data/node.main.75. Accessed September 3, 2013.
- The author spent two months, June-August 2013, in Ethiopia conducting interviews in the Addis, Oromiya, Amhara, SNNP, and Tigray Regions.
- “Ethiopia Demographic and Health Survey 2011,” Central Statistical Agency (Addis Ababa, Ethiopia and Calverton, Maryland, USA: ICF International, March 2012).
- Mothers2Mothers. http://www.m2m.org/what-we-do/where-we-work/south-africa.html. Accessed September 3, 2013.
- The Ministry of Health has introduced the health care financing system, wherein user fees are added to the budget the centers receive from existing federal and regional block grants. This helps them to manage their own budgets and address the problems that are most pressing at their site.
About the Author
Kate Klein is an MPH student in the Program in Public Health, Feinberg School of Medicine, Northwestern. She also serves as the Assistant Director at the Program of African Studies at Northwestern. She recently worked with IntraHealth International as part of her internship with USAID’s Africa Bureau in five regions of Ethiopia.