Establishing the Ethiopian Obstetric Surveillance System (EthOSS): building a regional network to monitor severe outcomes of pregnancy

Background: Despite efforts by the United Nations and many governments around the world to reduce the number of women who die during pregnancy and around childbirth, 295 000 women still died during pregnancy and childbirth in 2017, 99% of whom in low- and middle- income countries (LMIC), particularly sub-Saharan Africa. In Ethiopia alone, around 14 000 women died the same year (highest number following Nigeria, India and DR Congo) and it appeared that the national maternal mortality ratio had even increased from 353 to 401 per 100 000 live births in the course of two years. Efforts to reduce maternal deaths and disability in Ethiopia are hampered by lack of reliable data. In order to develop targeted interventions and measure progress towards achieving the sustainable development goals, there is an urgent need to institute robust registration of maternal mortality and morbidity, and collect associated data to assess quality of care. Such registrations and enquiries were previously found to contribute importantly to the reduction of maternal deaths in the UK and other high-income countries.

Objectives: establish a regional Ethiopian Obstetric Surveillance System (EthOSS) network to monitor severe maternal complications in twelve maternity units in Eastern Ethiopia and examine feasibility to implement a national EthOSS network in Ethiopia.

Methods: This project involves four inter-related activities: 1) establishing a regional network and EthOSS consortium, 2) case registration on specific severe maternal outcomes, as defined by the consortium, 3) collection of detailed management data for confidential enquiry into one selected condition, and 4) establishing criteria for feasibility of a national EthOSS consortium and network.

In the first phase (2-3 months), we invite all potential stakeholders (federal ministry of health, professional societies, community representatives and participating facilities) to take part in the network consortium. Under the leadership of College of Health and Medical Sciences, Haramaya University, Ethiopia, and the National Perinatal Epidemiology Unit (NPEU), University of Oxford, UK, a regional start-up meeting will be held, during which reporting criteria for mortality and morbidity are chosen. In the next phase (6 months), nominated clinicians at each of the twelve participating maternity units will report cases (including maternal deaths and cause of death) from selected conditions into a secure REDCap database. EthOSS researchers will confirm cases by visiting reporting units. Additionally, more detailed management items pertaining to cases from one condition (to be determined during the start-up meeting) will be collected to assess quality of case management for that condition by performing confidential enquiry. At the end of six months, quality of the EthOSS database and reported information will be evaluated by the consortium. A detailed review/confidential enquiry of cases from the priority condition will lead into a regional report on that condition. The final three months, feasibility of scaling up surveillance to national level and perceived challenges will be evaluated. Based on this evaluation of feasibility, the network will write a larger grant proposal in order to initiate a national EthOSS network, in close collaboration with the federal ministry of health, national professional organizations and client representatives.

Expected outcomes: The possibility to introduce a regional, simple but robust registry of severe maternal complications in an LMIC in sub-Saharan Africa is examined for the first time. This will help to determine the burden of maternal mortality and other severe complications in the region. Use of detailed management data and confidential enquiry will generate evidence on quality of obstetric care and identify opportunities for improvement. Finally, a package of feasibility criteria for national surveillance is created.

This project is designed to assess feasibility to establish a user-friendly maternal morbidity and mortality surveillance system, entitled Ethiopian Obstetric Surveillance System (EthOSS), which aims to assess prevalence of mortality and severe morbidity from priority pregnancy-related conditions. The possibility to establish EthOSS will be piloted in the Eastern Ethiopian region.
Specific objectives include to: i) establish a regional EthOSS consortium between twelve maternity care institutions and key partners, ii) start case registration for severe maternal outcomes deemed most important by the consortium in these maternity units and their catchment areas, iii) pilot detailed clinical management-related data collection on one single severe pregnancy outcome as selected by the consortium, enabling assessment of quality of management for that specific condition, and iv) arriving at a set of feasibility criteria for establishment of a national obstetric surveillance system in Ethiopia.
Regional EthOSS will be established by adapting the United Kingdom Obstetric Surveillance System methodology to the Ethiopian context. Including members from the Federal Ministry of Health, professional societies and community representatives, the consortium will select conditions for registration and pilot data collection for six months in twelve maternity units representing different levels of specialization (university hospitals, regional and rural district hospitals). In each unit, a nominated clinician will report cases (including maternal mortality and cause of death) from these conditions. Case ascertainment will be done by EthOSS researchers. The sample of cases with detailed management-related data will lead into a regional confidential enquiry report for the priority condition. Finally, the entire consortium, together with national stakeholders, will evaluate regional implementation of EthOSS and establish feasibility criteria facilitating possible nationwide scaling up.

First and foremost, pregnant women and their babies will benefit from improvements in quality of maternity care resulting from improved mortality/morbidity data collection and care assessment, in eastern Ethiopia to begin with and in the rest of the country and the wider region at later stages. Almost all of the 14 000 maternal deaths that occur in Ethiopia every year are potentially preventable with access to better maternity care, and the same goes for the much larger number of deaths in the rest of Sub-Saharan Africa. Improved morbidity registration combined with targeted interventions, as well as careful quality of care analysis combined with effective communication of lessons learned are crucial to prevent these deaths.

Findings from this project will be beneficial to policy makers within the Federal Ministry of Health, the Ethiopian Society of Obstetricians and Gynaecologists, and other leading policy makers aiming to improve maternal health in Ethiopia, so that they may design more appropriately targeted interventions addressing the main morbidities and quality gaps identified. Learning about pathways to feasibility may inform the Federal Ministry of Health as to how to implement obstetric surveillance and action at a national level, and assess progress towards reaching the 2030 Sustainable Development Goals.

Additionally, findings will feed into revisions of national guidelines for clinical management of obstetric complications. Topics for professional trainings will be identified from maternal death and morbidity reviews. Therefore, it is expected that our study findings will impact importantly on the capacity of the health work force. Since our project includes the study of morbidity in addition to mortality, we expect to have a larger and more positive impact on health workers and policy makers, who may be put off by assessments of mortality alone. Morbidity registrations generate more data, enable client interviews into quality of care assessments and may include more positive lessons learned with regard to how a woman survived a severe complication. These are all extremely important elements pertaining to morbidity surveillance in order to generate motivation for the surveillance system and sustain its impact.