Learning from Ethiopia's success in reducing maternal and neonatal mortality through a health systems lens

Abstract

Background: This study aimed to enhance insights into the key characteristics of maternal and neonatal mortality declines in Ethiopia, conducted as part of a seven-country study on Maternal and Newborn Health (MNH) Exemplars.

Methods: We synthesised key indicators for 2000, 2010 and 2020 and contextualised those with typical country values in a global five-phase model for a maternal, stillbirth and neonatal mortality transition. We reviewed health system changes relevant to MNH over the period 2000-2020, focusing on governance, financing, workforce and infrastructure, and assessed trends in mortality, service coverage and systems by region. We analysed data from five national surveys, health facility assessments, global estimates and government databases and reports on health policies, infrastructure and workforce.

Results: Ethiopia progressed from the highest mortality phase to the third phase, accompanied by typical changes in terms of fertility decline and health system strengthening, especially health infrastructure and workforce. For health coverage and financing indicators, Ethiopia progressed but remained lower than typical in the transition model. Maternal and neonatal mortality declines and intervention coverage increases were greater after 2010 than during 2000-2010. Similar patterns were observed in most regions of Ethiopia, though regional gaps persisted for many indicators. Ethiopia's progress is characterised by a well-coordinated and government-led system prioritising first maternal and later neonatal health, resulting major increases in access to services by improving infrastructure and workforce from 2008, combined with widespread community actions to generate service demand.

Conclusion: Ethiopia has achieved one of the fastest declines in mortality in sub-Saharan Africa, with major intervention coverage increases, especially from 2010. Starting from a weak health infrastructure and low coverage, Ethiopia's comprehensive approach provides valuable lessons for other low-income countries. Major increases towards universal coverage of interventions, including emergency care, are critical to further reduce mortality and advance the mortality transition.

Keywords: Child health; Health policy; Health systems; Maternal health; Public Health.

Figure 1. Maternal mortality ratio (per 100 000 live births) by stillbirth and neonatal mortality rate combined (per 1000 births), based on UN mortality estimates for 151 countries, with Ethiopia (ETH) (red dot), sub-Saharan Africa (SSA) (blue dot) and world (black dot) highlighted, 2000 and 2020. Others refers to the 149 countries with population of atleast 1 million. Each dot represents point estimates of mortality (ETH, SSA, World and 150 other countries) for 2000 and 2020.

Figure 2. Trends in key indicators of antenatal care (ANC first visit and four or more visits, ANCq is with contents and timing)*, delivery care (institutional births and C-sections) and family planning (demand satisfied with modern methods among currently married women), Ethiopia DHS 2000–2019. DHS, Demographic and Health Survey; MHN, maternal and newborn health.

Figure 3. Timeline for key events, policies, strategies and programmes relevant to maternal and newborn health (MNH). IMNCI, integrtaed management of neonatal and childhood illness; IMCI, integrated management of childhood illness; SDG, Sustainable Development Goal; HSDP, Health Sector Development Plan; HSTP, Health Sector Transformation Plan; MNH, maternal and newborn health; HDA, Health Development Army; WDA, Women Development Army.

Figure 4. Trends in health workforce (by 10 000 population) and health facilities (by 100 000 populations), Ethiopia, 2000–2020. GP, general practitioner.

Figure 5. Trends in neonatal mortality rate (per 1000 live births) of Ethiopia by region, 2000–2017. SNNPR, Southern Nations, Nationalities and People’s Region; B-Gumuz, Benishangul-Gumuz.

Figure 6. Key indicators of maternal and newborn health intervention coverage by region, DHS surveys in 2000, 2005, 2011, 2016 and 2019. ANC1+, antenatal visits for pregnancy: 1+ visits; ID, representing place of delivery at health facility; FP, representing demand for family planning satisfied by modern methods (the 2019 data point for FP was linearty inputed using four previous rounds of data). ANC, antenatal care; DHS, Demographic and Health Survey; FP, family planning; ID, institutional delivery; SNNPR, Southern Nations, Nationalities and People’s Region; B-Gumuz, Benishangul-Gumuz.