Helena Getachew

Period 3
January 21, 2016
HG: So, can you describe to me the setting of a rural hospital in Ethiopia?
What is it like in the maternity unit?
LT:

So in a primary level, when you say a rural hospital, so Ethiopia has

3, uh, levels in the health care system, the primary health care unit is the
lowest one. So that primary health care unit has, of course, health posts,
health centers that the hospital is the primary care hospital in that level.
And, uh, essentially it would have, uh, a labor and delivery room. Uh, if you
start from the outpatient, then it would have an antenatal clinic, where the
pregnant women would come to get the, uh, regular follow up, so it would
be just a one room setting with a desk a table for the, uh, usually could be a
nurse or a health officer or a physician who keeps all the examination
cards. So there would be one room for that. Usually, there would be
another for family planning, and so on, next to it (the antenatal clinic). And
then, if its a hospital then it will have a labor and delivery service, even
health centers would have labor and delivery services, but the, uh,
hospitals, theyre a little bit bigger, so they would have, maybe, an up to
four bed labor room and a two bed delivery room. Usually, the labor and
delivery room are separate rooms.
HG: Right, okay.
LT:

Once theyre in, uh, almost to deliver they will be transferred to the

delivery room, and there will be a unit and corner where, when the baby

comes out, the baby is taken to be resuscitated, and dressed, and kept
warm, and so on. And, there will be a postnatal room where the woman,
after the delivery, would be taken. Um, if its a normal delivery 6-24 hours,
and, typically, the primary hospitals may not have the facilities for
operations, but, mostly now, most of them are now becoming upgraded to
have, uh, services, I mean, an operation room, where they can have
emergency C-Sections or elective C-Sections, so there would be rooms for
mothers, uh, maybe. Four beds or six beds in one room where the mothers
would, uh, after the delivery, would be spending time to until they recover,
so if they do C-Section, then they will stay for maybe five to six days, as
opposed to a normal delivery where they are discharged the same day. So,
typically, thats, so there would be a ward with some beds, maybe, one per
postnatal room, maybe or two (postnatal rooms). Each room would usually
have six beds per postdelivery. Uh, what else? More or less for women, for
mothers this it what they would have.
HG: Do you think there are enough staff members for all of the patients
that come and go through these hospitals? Would you say that?
LT:

No, there wouldnt be enough. Nowhere would we have enough staff

members. There may be enough nurses, even that would not be enough
for all of them in low parts of the country. The more rural areas, uh, still
have, uh, very few nurses, so physicians its hard to find facilities in rural
areas, so they may have health officers. Health officers are trained for four
years, uh, to work, maybe somehow the physician works in this part of this
country. So they would give the service to, no neonatal surgeries or
anything for these women, so, uh, there is a standard for how many

physicians, how many nurses, and so on should be for each bed number
by the country, but usually that standard would not be met, especially in the
more rural areas.
HG: Oh, okay. Um, so, what are Ethiopias leaders doing to reduce the
exposure to those contractible diseases, like tuberculosis, in those
hospitals located in those more rural and impoverished regions? Is the
Ethiopian government really doing much to solve those problems?
LT:

Yes, a lot. So, for the past twenty years, the government has been

working on a five-year plan, every five years. So they are writing, every five
years, the progress that has been made, so there has been quit, uh, a lot of
achievement, a lot of reducing infectious diseases, especially malaria, or
HIV, and tuberculosis. So, especially, the reductions in the prevalence of
HIV and malaria has been significant. Malaria mainly because there was a
house-to-house distribution of, uh, malaria insecticide treated bed nets for
households all over the country, not all over the country, but mostly in
malaria-epidemic areas. So, that has molded the significant reduction in the
prevalence of malaria. And for HIV, mostly, has been awareness of creation
and ensuring that antiretroviral therapy is given for those who need them.
That was possible, of course, because of global funding from mostly the
United States and other countries, so, by assuring this, uh, screening,
prevention, awareness, and also treatment of those who already have HIV,
has really significantly reduced the prevalence from 2.something to
0.something now.
HG: Wow.

LT:

So, the prevalence is very low now, but still the work is continued.

Tuberculosis has been reduced, but still the challenge is there, especially,
the biggest challenge is now among the resistance. The multi-drug
resistance, you know, of tuberculosis, so a lot of work is being done still to
create awareness and treatment is still being done. For, a lot of things like
the high mortality rate, but also child and infant mortality, if you see the
MGG goals there has been significant achievement to the targets of MGG,
especially in child and infant mortality, and, also, there is some reduction in
maternal mortality, even though it hasnt reached the MGG goals for
Ethiopia. And this has been mainly by its function of its primary health care
program, and, I dont know if this would be very interesting for you, but you
can read about the health extension program the ministry is known for. By
deploying health extension workers, these are like community health
workers, all are female so there are around 35,000 trained in the country,
so two are assigned for each of the kebeles, you know kebeles are the
units, so they are each going there, going house-to-house, teaching the
public and also giving vaccines, family planning. Even they are trained to
insert the contraceptive implants, so they are going there to give their
service and also they are stationed two days per week in the health posts,
giving services. So, that has dramatically improved a lot of problems, uh, in
the country, and, of course, there has been a lot of infrastructure expansion
by building health centers and hospitals. And, of course, if you build all
those health centers, and, even if you have the workers, it doesnt, uh,
address all of the spectrum. So the government has also been expanding
the medical schools. So, when I was trained as a medical student they only

had three medical schools, and within the last fifteen years we have
reached thirty medical schools- three zero.
HG: Wow.
LT:

So there has been a significant expansion, uh, in terms of, of course,

theres always a concern when you expand like this in huge amounts, so,
nowadays a lot of partnerships, like what we do now at the University of
Michigan, give a lot of support in developing the capacity of the teachers,
the faculty who teaches at those universities and the quality is also coming
up now.
HG: Wow, okay. Um, do you think that traditional practices, such as one
that I saw from prior research, female genital mutilation, or female
circumcision, do you think that those practices halt Ethiopias maternal
health progress? Or is it just preserving culture?
LT:

Hm, so these practices, they impact maternal health, theyre not the

biggest burden of maternal mortality, most of it is not coming from those

practices, but its mostly from home deliveries, early pregnancies, but still.
This is also a practice that, uh, especially in certain parts of the country, so
this practice has been significantly reduced by different awareness
creations and the teaching of the community, but still is being practiced in
some parts of the country. There are few areas in the country where its
strictly still practiced, but, in most parts, its been significantly reduced. And
if it is practiced, usually, the lowest types of female genital cutting and the
severe form is not usually practiced in most places. So, the burden of it is
decreasing, but still the problem is there, but mostly the problem of

maternal mortality is related to teenage pregnancies and, also, uh, not

accessing health services during delivery.
HG: That makes sense, so all of these problems generally stem from
poverty and lack of awareness.
LT:

Even if its not poverty, some of the awareness of the need to seek

health care for delivering because most consider it a natural process.

Women and families dont tend to seek health care for normal deliveries,
unless there is a problem, and sometimes it may be too late already when
they are delivering for long hours at home. So thats a major challenge, and
sometimes, even if they are aware, they may be too far from those facilities
where there is no infrastructure and sometimes when they get to the
hospital it may be too late and they may not get that quality care. So there
are different points, but mostly its related to those areas.
HG: Okay, um, this goes back to that whole cultural aspect of it, but, um,
do you believe that Ethiopias male population is doing enough to support
maternal and neonatal health? Do you think that theyre doing enough?
LT:

The male population? So, when you say male you mean the

community or those in the health sector?

HG: Those within the community.
LT:

Okay, so, interestingly, there has been a lot of change, recently. So,

one of the new things that the government is doing, uh, with the health
extension program at the community level is whats called the Health

Development Army program. So, what that means is, they develop
networks of households within the community where five households are,
uh, the head of one network. They meet regularly, so the men would meet
and the women would meet regularly to discuss all issues like the health of
their children, hygiene, do you they have toilets appropriately made, do
they have to have their child vaccinated. If a woman is pregnant, they make
sure she follows up with her care and make sure she deliveries in a health
sector or a hospital. So, uh, these networks, when they do well, then one of
them would be rewarded, and the leader of this network would be
recognized by the government, and so on. So, they (the men) strive a lot,
but, mostly, its seen that the women do a lot of the work in creating this
momentum. But still, the men are also now engaged in those activities to
ensure that they have all these, uh, things to prevent, like ensuring they
have a toilet, ensuring the children are, uh, fed well with the teachings that
they get about nutrition, and that they have the vaccines, and so on and so
forth to make sure that the wives, when they are pregnant, uh, get the
service they need. And, sometimes even when a women is in labor, the
men in those areas would, if they are too far from the facility and there is a
long road and no access for a car, the men would carry the women and
take her to the facility. So, there is this community engagement happening
now that the government is really working on, especially the networks work
a lot in advising this and now the ministry has developed both a twentyyear visioning plan and a also a five-year transformation plan. So, theyre
really trying to engage the community, and, uh, male involvement is
changing, of course, its not where we want it to be, but its changing.
HG: Thats good to hear.

LT:

Yes.

HG: Do you think, just in general, that Ethiopia needs to improve its
maternal and newborn health system? If so, specifically what areas. I know
youve addressed some of this before, but what do you think is the most
important area that needs to be targeted is?
LT:

Still, there is a lot to improve, and I think that, uh, one of the biggest

areas is, uh, first and foremost, women to be able to only conceive when
they want to. So, ensuring the access to family planning is really key still
because, even if the usage of modern contraception is really increasing,
there are a lot of women who want to use contraceptives, but are not using
them. So, ensuring that the women have access to family planning so that
we dont have to worry about giving them quality service for delivery, and
so on, if they are not pregnant in the first place. So, to ensure that they
dont conceive when they dont want to. And then, once the women wants
to conceive and she is pregnant, getting access to, not just to maternity
health care and delivery, but quality maternity health care and quality labor
and delivery services where the women are treated they way they want and
get the care they should get, but timely. Especially in the timely care,
sometimes the women even go to hospitals and sometimes still end up
either losing their child or losing their life. Uh, and for that then goes the
quality of training is what matters. Training the medical students, the
midwives, the specialists, quality training to make sure that they are
competent, but also compassionate, uh caregivers, so having that standard
of quality training. Currently, the Ethiopian society of OBGYN, for example,
here at the University of Michigan we are trying to work with creating

standards for training for the different residency programs being open
because, not only are the medical schools expanding, also the residency
programs and the speciality programs are growing in the country, so there
are really high set standards on how they should run, what the
competencies are for each of the programs, and so on. So, ensuring the
quality of the training so that we have quality professionals who can give
the care, and then, of course, having the necessary infrastructure, also, the
facilities, and equipment that also has been improving, but still, uh, needs
some work. So, mostly focusing on the human resource needs and also
accessing the services is what needs to be done.
HG: One last question, what role does education play in the field of
maternal and newborn health?
LT:

Well, uh, Ive mostly said it, as you know, but it is a critical component

to address staffing from the training of extension workers who give the,
uh if the education of the professionals is there, of course, the education
of the women is there. So, if the women are educated, as in they would
know when to conceive, where to get the access, where to go for prenatal
healthcare, where to go for delivery, and so on, so this is all key in
empowering women to take care of themselves, if they are educated. On
the other face of educating, is educating, uh, the health professionals in a
standardized way (with) quality training that ensures the necessary care for
women, timely care, compassionate care, skilled care, so, uh, the quality of
education is not just them having the number of adequate professionals
who can give care, but also the adequate quality of professionals, uh, the

qualified professionals who can give quality care. So, it has both
spectrums: education for the women and for the professional.
HG: Okay, thank you so much!
Evaluation:
Overall, the interview was a success. I obtained a lot of new
information, such as what Dr. Lia considered to be the most significant
factor that halts Ethiopias maternal and newborn health progress: access
to contraceptives and proper training for medical professionals. Also,
countering my original negative perception of the role of men, Dr. Lia
provided me with the numerous ways on how men contribute to Ethiopias
maternal health efforts. Ideally, I wouldve preferred to have conducted this
interview face-to-face, rather than over Skype, for I feel as though those
intimate and powerful moments were lost. In addition, the call quality was
sub-par, making it quite difficult to interpret what she was saying and, when
the interview was completed, to transcribe. The hardest aspect of preparing
for this interview was composing the questions. I had to consider
redundancy and fluidity, but also make sure that I was including all of the
content that I wanted to address. With that being said, I took my time when
formulating my questions, outlining what ideas I wanted to address
beforehand.