Shewit Tekeste, PHO, MS, is Director of the Adiakala Health Center. He is a Primary Health Care Unit director and quality improvement head and mentor for PHCUs, schools, and health posts.
I grew up in rural Samre woreda (province) in Ethiopia, where my community was faced with a lot of maternal mortality. This is a concern in and of itself, and it also leads to another issue: the number of orphan children in my community who grow up without a parental figure. These issues motivated me to work on reducing maternal mortality rates, and quality improvement (QI) approaches allowed our team to achieve progress.
My journey began in July 2018. Samre had 10 preventable maternal deaths that year, the highest in the region. Contributing factors included residing far from the facility, poor road conditions, and a lack of ambulance services. My town has a population of 151,482 persons, yet we only have two ambulances, coupled with either very bad roads or in some places no roads at all.
For this work, QI committee members and health extension workers (HEWs) were provided with basic QI and clinical training. They learned to set an aim, choose indicators, and test changes using a Plan-Do-Study-Act (PDSA) cycle.
The team completed QI and clinical training.
After identifying the root causes of the maternal deaths, the team tested six high-impact change ideas to increase the number of deliveries that happened in a health facility:
At a “pregnant conference,” where pregnant women in the community gather to talk with each other, we shared information about the risks of delivering at home and the benefits of coming to a facility for deliveries.
The community in my province is Christian and very religious. We involved community religious leaders – in this case, priests – in maternal health to advocate for mothers to deliver at a facility.
The team spread awareness of existing services. Ambulance service is limited, as mentioned earlier, and requires a financial solution. However, we wanted to make sure mothers knew what was available.
We presented in schools to teach children about maternal health so that the students could discuss the benefits of the facilities with their mothers.
The community has a lot of fear of the facility, which is partly what prevented them from coming. We invited the mothers to visit the delivery rooms before giving birth. During these visits, the team explains how we will protect their privacy and take care of them.
One simple change idea was simply that the team encouraged mothers to come to the maternal waiting room at a facility. The maternal waiting room is organized for mothers whose gestational age is greater than 38 weeks, mothers who have medical problems, and those whose home is more than eight kilometers away from the facility. Mothers can stay there for up to three weeks. During that time, they have access to daily vital checks and health education.
To bring women to the maternal waiting area, we list pregnant mothers who had started antenatal care in the facilities or who were identified through volunteers in the Women Development Army, a community health entity established by the Ethiopian government. The HEWs then advise women whose gestational age is more than 38 weeks to come for antenatal care and counsel them to come to stay in the maternal waiting rooms.
Maternity waiting rooms include a daily monitoring routine and provide interventions like iron folate, mebendazole (to treat worm infections), and tetanus toxoid immunization as appropriate. We aim to create a home-like environment and empower mothers with birth preparedness, identification of maternal and neonatal danger signs, neonatal care, breastfeeding, family planning, and other individualized care.
By applying QI approaches, our facility brought about what was previously considered unimaginable change. Maternal deaths went from 10 deaths in 2018 to only 1 death in 2019. The number of home deliveries was sliced in half, and we saw an increase in vaccination coverage and post-partum family planning. The health-seeking behavior of the community has changed. Our team has changed; we now have planning and monitoring processes. QI brings new ideas to our lives and eases our work and responsibilities. Some of us have even expanded these approaches to our personal lives.
This project allowed me to understand that a huge financial investment is not necessary to be able to make a difference. Working on such projects creates team spirit among health workers while planning, measuring, and working together, and this team spirit is extremely necessary and important for the work. I have been able to share these approaches with other facilities, and our team has used QI in a variety of projects, including increasing syphilis screening, improving antenatal care coverage, and managing and diagnosing preeclampsia. QI is now expanding to more areas, and I am confident it will improve our health care system and facilities.
Lessons from this work will
be shared as part of the IHI Africa Forum on Quality and Safety in Healthcare,
originally scheduled for May 2020 and now postponed. Sign up to be notified when more information becomes available about new dates
for the IHI Africa Forum.