The population of Ethiopia is estimat-ed at 86 million in 2012 with an an-nual population growth rate of 2.6 per cent.1 With only 15 per cent of

the total population living in urban centres, Ethiopia is one of the least urbanized coun-tries in the world.2 Still, with pro-poor ex-penditures representing around 70 per cent of government expenditures in 2012/13, the Government of Ethiopia continues to show strong commitment to human and social development which helps the country make impressive progress towards attaining most of the Millennium Development Goals (MDGs). MDG 4 of child mortality reduction has been achieved three years ahead3 and MDG 6 of halting the spread of HIV/AIDS, Malaria and TB is well on track towards the 2015 deadline.

However, MDG 5 of improving maternal health has showed a slow progress. WHO indicates that annually, 287,000 women die globally during and following complications of pregnancy and child birth. Over 99 per cent of these deaths occur in low-resource settings, and most are preventable through provision of quality essential maternal health services. In 2012, about half of all maternal deaths were in Sub Sahran Africa Region.4

Although Ethiopia has reduced under � ve mortality rate (U5MR) by two thirds be-tween 1990 and 20125, meeting the target for MDG 5, progress in Maternal Mortality Ratio (MMR) reduction has been slow. Only 29.5 per cent women delivered in Health Fa-cilities6. MMR is 676 per 100,000 live births7 while the expected MDG 5 target is to bring the level below 267 per 100,000 live births by 2015.

1. Ethiopian CSA, Census 2007 Report

2. Ethiopian CSA, Census 2007 Report

3. UN IGME 2013

4. WHO 2012

5. 2013 report from the UN Interagency Group for Child Mortality Estimates (IGME)

6. EFY 2006 report of the Federal Ministry of Health

7. EDHS 2011

Trend of progress towards MDG 5 in Ethiopia8

Indicator 1990 2000 2005 2010 2013

Maternal Mortality Ratio (MMR) 1067 871 673 676 --

Skilled Birth Attendance - 4% 5% 10% 29.5%

Antenatal Care Coverage (at least 1 visit) - 27% 28% 34% 89%

In addition to the MDG targets of reducing the MMR to 267 per 100,000 live births, the Federal Ministry of Health (FMoH) has also set other ambitious targets for 2015 including availability of Basic and Comprehensive Emergency Obstetric and Neona-tal Care (BEmONC and CEmONC) at 100 per cent of hospitals and health centres in the country; increase skilled birth attendance rate to 62 per cent of total deliveries and universal access of mothers and neonates for antenatal and postnatal care.9

In Ethiopia, up to 15 per cent of mothers and new-borns suffer serious complica-tions that warrant referral to facilities providing comprehensive emergency obstetric and neonatal care (CEmONC) services including caesarean sections, blood transfu-sions and emergency laparotomy. However, the availability of CEmONC has been limited with only over a hundred hospitals having the capacity to provide the service in the country.10 In order to increase access, FMoH has committed to the construc-tion of over 800 new primary hospitals [one primary hospital per woreda (district)]. Nationally, the construction of over 200 primary hospitals has already been initiated in the various regional states and is expected to be completed soon.11 The hospi-tals need to be equipped with basic essential supplies and equipment to provide maternal and neonatal care including equipment for basic operation facilities and essential neonatal care equipment. The rapid inauguration of these primary hospi-tals will enhance the national capacity to provide continuous care and increase the accessibility of essential emergency obstetric and neonatal care to the majority of mothers and new-borns.

During the last decade, Ethiopia has made remarkable progress to reduce U5MR between 2005 and 2011 from 123 to 88 per 1,000 live births (reduction of 28 per cent), but the Neonatal Mortality Rate (NMR) shows slow progress and now ac-counts for 42 per cent of under-� ve deaths.12 This burden is even greater for the large rural population due to poor access and utilization of maternal and new-born health services. To further reduce U5MR, NMR and its major direct causes such as sepsis, birth asphyxia, and pre term delivery must be addressed through the provi-sion of quality delivery services to all mothers coupled with essential new-born care provision to all new-borns. Neonatal sepsis, the major new-born killer, accounts for more than one third of neonatal deaths. Seventy � ve per cent of new-born deaths occur within the � rst week of life, when even modest delays in receiving effective care can be deadly. A relative gap in service outlets exists at hospital level with the majority of the expected 800 district hospitals [one per each woreda (district)] still under construction or not yet began. At present, just over 120 hospitals are provid-ing CEmONC services for the entire population of the country.

8. EDHS 2000, 2005, 2011

9. Health Sector Development Program IV, FEDERAL MINISTRY OF HEALTH (HSDP IV), 2010

10. National EmONC Assessment Report, FEDERAL MINISTRY OF HEALTH, 2008

11. 2012/13 Annual Review Meeting (ARM) Report, FEDERAL MINISTRY OF HEALTH

12. EDHS 2011

Ethiopia - Maternal Health Brief

Unite for a Safe Delivery in Ethiopia

የኢ.ፌ.ድ.ሪ. ጤና ጥበቃ ሚኒስቴርFDRE Ministry of Health

European Union

Unite for a Safe Delivery in Ethiopia

There are also signi� cant additional challenges to the implementation of more complex interventions such as case management of neonatal sepsis at the community level including supply and logistics for provision of essential medicines to community health care outlets and low levels of timely health seeking behaviour by mothers and communities. However, important and unique opportunities also exist in Ethiopia to improve service delivery through both community and health facility based interven-tions. Results achieved and lessons learnt in the last 17 years of health sector development programme (HSDP) implementation to improve the health of mothers and children indicate the following:

1. The Health Extension Programme (HEP) imple-mented by the FMoH with the support of devel-opment partners has led to a signi� cant increase in potential health service coverage from a very low point to nearly 98 per cent of the total pop-ulation. The preventive, promotive and basic cu-rative services provided to the majority of the population13 including mothers and children have increased the access to essential health care. The results achieved are substantial including a tremendous reduction in child mortality, increase in the contraceptive prevalent rate from 4 per cent in 2000 to 29 per cent in 2011,14 decrease in malaria mortality as well as improved sanita-tion services. The recently introduced Health Development Army (HDA) initiative introduced in the larger regions; Oromia, Amhara, Tigray and SNNPR is expected to increase the demand and utilization of essential services as shown in the tremendous increase in skilled delivery rates from a very low baseline of 10 per cent to nearly 30 per cent in the last half year.15 It is clear that support to the HEP and HDA initiative should be sustained to further augment health knowledge and health seeking behaviours so that more and more mothers and neonates will access the available and increasingly expanding essential health services.

2. A progressive healthier delivery system exists with the Primary Health Care Unit (PHCU), inclu-sive of � ve health posts and one health centre, being the point of entry into the health system. Expansion of the PHCU is currently nearing com-pletion as far as facility construction is concerned with nearly 16,000 health posts and 3,400 health centres completed and most of them already providing services as equipment and staf� ng is proceeding.16

13. Health Indicators 2004 EFY, FEDERAL MINISTRY OF HEALTH

14. EDHS 2011

15. HMIS mid-year report for EFY 2006

16. FEDERAL MINISTRY OF HEALTH, Health Indicators 2005 EFY

3. Referral System Strengthening also resulted in procurement of 800 ambulances (one per wore-da). There is also a new Mater-nal and Neonate Health (MNH) quality improvement initiative of Maternal Death Surveillance and Response (MDSR) introduced re-cently to identify cause of death.

While it is clear that the current efforts to � ll the gap in access to health care through the construction of health facilities including health centres and hospitals is commend-able, concurrent efforts should be enhanced to ensure that the new-ly constructed facilities are fully equipped with essential utilities to provide quality maternal and neona-tal lifesaving interventions as soon as possible. In addition, training of new staff and retraining of existing staff in basic maternal and neona-tal care skills is a matter of urgen-cy in light of the massive increase in health service outlets. Financial as well as material support is re-quired to the public sector to meet the HSDP as well as MDG targets in time. This will include support to the MDG Pool Fund as well as direct support to procurement of essential supplies and equipment for maternal and new-born care.

In order to improve the health care � nancing as well as to reduce the burden of health care cost on moth-ers and families, FMoH has institut-ed the national Health Care Financ-ing Reform (HCFR).

The HCFR includes fee waivers and exemptions for maternal and child health care services; user fee reten-tion and utilization by health facilities to improve essential services; pilot-ing of community health insurance schemes; progressive increase in national health budget and better harmonization of health related aid through mechanisms such as the MDG Pool Fund.

Financing the procurement of es-sential drugs, supplies and equip-ment for health centres and hospi-tals including those for emergency surgery is one of the challenges fac-ing the FMoH. The challenge has become broader following the deci-sion by the Government to provide all maternal and basic neonatal care services free of charge to all moth-ers accessing care at public health facilities. The rapid expansion in the number of health centres and hos-pitals is also another challenge as it has enormously increased the de-mand for essential utilities.

European Union, UNICEF and other development partners are closely collaborating with the FMoH to sup-port the national effort to achieve the goals of the MDGs with partic-ular focus on reduction of maternal and neonatal mortality. The recently initiated collaboration between the Government of Ethiopia, the Euro-pean Union and UNICEF Ethiopia on the Enhancing Skilled Delivery in Ethiopia (ESDE) project is planned to be implemented nationally with the objective of assisting the national ef-fort to achieve MDG 5. The project is funded by the European Union with 40.2 million Euros for three years to work on enhancing health facility readiness to provide quality delivery and neonatal care services as well as support community mobilization towards utilizing lifesaving maternal and new-born health services. The project is expected to support the health service for an estimated 12.5 million people nationally. Every year the 625,000 mothers and neonates will directly bene� t from the project with improved access to maternal and neonatal health services. During the three years of implementation, the project will impact close to 2 mil-lion mothers and neonates.