Case study

Maternal mortality: Ethiopia


By Bill and Melinda Gates

If you were trying to invent the most efficient way to devastate communities and put children in danger, you would invent maternal mortality.

So the fact that the number of mothers who die has been cut in half in the past generation is one of the more important successes in global health. It’s all the more impressive because reducing maternal mortality is really hard.

Statistically speaking, it’s rare compared to, say, child mortality. That’s why maternal deaths are rendered per 100,000 live births instead of per 1,000. Therefore, for every new solution that saves a mother’s life, you need to deliver 100 times as much of that solution to have the same impact.

Luckily, solutions already exist. To deliver those solutions to all women, the most important priority is persuading them to give birth in health facilities, where they can get skilled obstetric care, instead of at home. We asked Kesete Admasu, former minister of health of Ethiopia, to write about how his country created a health infrastructure that helped women make this decision.

As Dr. Kesete suggests, as this shift from home to facility births continues, the maternal health community must make sure that the obstetric care provided in facilities is of the highest quality. With many more mothers delivering at facilities, it puts new pressures on health systems—they need more equipment, more staff, and more training. With these resources, developing countries will continue to drive down maternal mortality at the accelerated rates of the past 25 years.

Maternal deaths per 100,000 live births in Ethiopia
Progress to date
Health Extension Program begins
Women’s Development Army launched

From the field

Kesete Admasu

CEO, Roll Back Malaria Partnership (former minister of health, Ethiopia, 2012–2016)

When I joined the Ethiopian Ministry of Health in 2002, we were using a health system designed for other countries.

Our tiny number of highly trained health providers concentrated in big cities, far away from the 85 percent of our people who live in rural areas. This mismatch led to some of the worst child and maternal mortality statistics in the world.

We were committed to saving those lives, but it didn’t make sense to put good money into a bad system. So we built a new one. Launched in 2003, the Health Extension Program gives Ethiopians the services they need, where they need them. We trained 40,000 health extension workers to provide basic information and care to all 100 million Ethiopians. The goal was to put knowledge and power—and, ultimately, responsibility—in the hands of local people.

Don’t let me give the impression that any of this was easy. We made mistakes, and we have shared lessons so that other countries can learn from our experience. But, generally speaking, the Health Extension System worked—and worked fast. Child mortality dropped by half in just eight years. We had proved our theory. When it comes to the things that save children’s lives—family planning, vaccines, bed nets, basic management of common illnesses—you can bring care to the community.

Child mortality dropped by half in just eight years. Maternal mortality, though, was a different story.

Maternal mortality, though, was a different story. It went down, but not nearly as much as child mortality. We knew why. To save mothers’ lives, you need obstetric care, and that happens in health facilities. But Ethiopian mothers overwhelmingly chose to give birth at home. Health workers advised women to give birth in health facilities, but they didn’t persuade many families to change.

By 2010, two separate strands of thinking had come together to suggest a possible solution to our problem. First, the Health Extension Program had always included the concept of model families, early adopters who did things like sleep under bed nets and use latrines—and whose example and leadership we hoped would inspire others. The idea: Model families create model communities, which lead to model districts and eventually to a model country.

Second, our colleagues in Ethiopia’s agricultural ministry had been experimenting with ways to help smallholder farmers use better seeds and modern planting techniques, and they’d had some success encouraging men to advocate within their communities.

We adapted that idea for health and used the model families we’d already trained to lead what we called the Women’s Development Army.

One health extension worker covers a community of 2,500 people or 500 families. That’s a world of improvement over the old system, but it’s still too many for the workers to build a deep personal connection with every person under her care. The Women’s Development Army, on the other hand, has 3 million members, one for every six families. They are not health professionals talking to community members. They are community members.

We adapted that idea for health and used the model families we’d already trained to lead what we called the Women’s Development Army.

They meet with women in the community every day over coffee ceremonies and every week at church or the mosque, and in short order they have helped changed the ecology of childbirth in Ethiopia. Between 2011 and 2016, the proportion of women giving birth in facilities increased from 20 to 73 percent.

It’s not just that the development army tells women in a community what those of us running the health system think they should be doing. It works the other way around, too. They tell us what the community wants us to do. For example, in the Tigray region, we learned that many women refused to give birth at facilities because they wanted their religious leaders to be present at the birth. Another concern: Women didn’t want to be carried on a stretcher, because others who left the village on a stretcher never came back.

Now, religious leaders go to the health facility, so that a safer birth doesn’t mean a birth divorced from people’s culture. We also designed a new stretcher just for pregnant women. We opened maternity waiting homes where women in their third trimester can stay close to the facility while they wait to go into labor. These were problems and solutions we’d never thought of, but the Women’s Development Army opened our eyes to the community’s needs.

Now that more Ethiopians are delivering in health facilities, there is more work to do: making sure that the quality of care facilities is uniformly excellent. That means a lot of things, including purchasing more equipment and medicines and training more skilled providers, which we are doing.

It also means keeping the community connected to the health system, which is why the Women’s Development Army will continue to play a pivotal role. We have found a way for Ethiopians to voice their demands to the health ministry. And when you have a demanding society, government delivers.

The stories behind the data

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