Midwifery in Ethiopia
Ethiopia is one of the most beautiful countries I’ve ever been to, and I would highly recommend visiting if you can! I was fortunate enough to visit in the summer of 2014, working with an organization providing support to people affected by HIV and AIDS. Healthcare in Ethiopia is faced with many struggles, namely poor infrastructure and inability to access resources due to mountainous terrain, but the expansion of midwifery is clearly helping in the realm of maternal and infant health.
While there, I was able to interact with many women, briefly discussing their experiences as best as we could with a translator (the main language spoken in Ethiopia is Amharic). While staying in the capital city (Addis Ababa), we took a day trip to Wenchi Crater Lake to see what the mountainous terrain looked like and to better understand many of the problems being faced by people living in remote areas.
A Brief History
Ethiopia is a sub-Saharan African country located in the Horn of Africa, bordered by Eritrea (to the north), Djibouti and Somalia (to the east), Kenya (to the south), and Sudan and South Sudan (to the west). Ethiopia has a rich history, and is Africa’s oldest independent country, never having been colonized– the closest thing to being colonized was a five-year occupation by Mussolini’s Italy during World War II. Christianity has been the state religion since the 4th century C.E., and religion has retained an important role in the lives of the people in Ethiopia, with the majority of the people being Coptic Christian.
Unfortunately, Ethiopia struggles with health care as well as many other issues, contributing to high maternal and infant mortality rates — infant mortality is at 48.3 per 1,000 and maternal mortality is at 353 per 100,000. The maternal mortality rate places Ethiopia at the 34th highest rate in the world. Although this is a staggeringly high number, it has gotten significantly lower over the past several years, decreasing from numbers as high as 743 per 100,000 in 2005.
This steady decrease can be attributed to initiatives to increase the standard of health care for these women, specifically through training midwives! Understanding the importance of correct prenatal care, skilled delivery, and postpartum care is absolutely necessary for the survival of these women and their children.
Some Demographics
Ethiopia has the second largest population in Africa, coming in at 102.5 million people. 83 to 84 percent of the population lives in rural areas with scarce resources and poor infrastructure. This means that there are major restrictions on access to established health centers for the majority of Ethiopians.
Health care centers and hospitals are being built, but there are fewer in the rural areas than ideal– it can take too long to travel to a health center, and many women face economic barriers as well. As such, in some rural areas, home birth rates are high, in some places reaching as high as 85%. The current population growth rate is 2.83%, and the total fertility rate is 4.91 children born per woman. The number of midwives in the country has been significantly lower than ideal, and the density of nursing and midwifery personnel per 10,000 people was only TWO from 2000–2009.
High maternal mortality rates can be attributed to many factors, including the lack of skilled birth attendants, inability to access health care, and the prevalence of unsafe abortions, just to name a few. Unsafe abortions are particularly worrying, considering that they account for up to 32% of maternal deaths in Ethiopia. However, maternal mortality rates and infant mortality rates have been steadily decreasing, which is due to the commitment to training more midwives and expanding their roles in the community.
Historical Role of Midwives
Traditional birth attendants have been used by Ethiopian women for centuries. These women are part of the community, and can be defined as “a person who assists the mother during childbirth and who initially acquired her skills by delivering babies herself or by working with other traditional birth attendants.”
These women are essentially lay-midwives, also known as direct entry midwives, gaining their skills through experience and apprenticeship. They are often older women and generally illiterate, most never having gone to school. They are the most commonly found midwives in rural areas, and are still relied on by many expecting mothers today.
However, they are being displaced by more skilled birth attendants today, and while their role has not gone away, it is decreasing in favor of the more highly trained midwives. Traditional birth attendants (TBAs) are often chosen for support and traditional reasons, such as allowing the presence of spouses and family at the delivery, as well as performing traditional practices that would not be done at a health center, such as rubbing the abdomen with butter and burying the placenta around the home. Midwifery has traditionally been looked down upon by students as well as community members and academicians, possibly contributing to the lack of training of TBAs.
Early Modern Midwifery
Finding information about official midwives in early Ethiopia is nearly impossible. The historical background of these essential healthcare providers and community members was not well documented throughout Ethiopian history. However, information becomes more available starting in the mid 20th century, specifically around the 1950s.
Professional training of midwives began in 1954, focusing on the nurse-midwife model. This entailed training as a nurse for three years, followed by six months to a year of specialized training in midwifery. This training first began at Gondar Hospital, and expanded to Princess Tsehay Hospital in 1959. However, only 7 people completed the training at Princess Tsehay Hospital, prompting the program to shut down in 1962. Gondar Hospital also shut down their program in 1964. After the closure of these programs, community nurses filled in the role of birth attendant between the 1960s and 70s, even though other training centers were still open.
An interesting thing to note about early modern midwifery in Ethiopia is the prevalence of male midwives. The number of male midwives has steadily grown, reaching 22% in recent years.
In 1986, the Addis Ababa Midwifery School opened with the support of the Swedish International Development Agency, and started to offer direct entry into a midwifery diploma program by 1998. However, the total number of midwives increased very little until the 2000s, having fewer than 1/3rd of the per capita number recommended. For example, in 1980, the total number of midwives in Ethiopia was 294.
Modern Midwifery
Modern midwifery in Ethiopia began in the late 1990s and early 2000s, and has grown considerably since then. The Ethiopian Midwives Association (EMwA) was formally established in 1992. It was registered by the Ethiopian Ministry of Justice in 1993, and was then registered under the Ethiopian Civil Society Organization Law. In 2000, the University of Gondar began offering a bachelor of science degree in midwifery, and in 2007 the Hamlin Midwifery College opened as part of a strategy to prevent obstetric fistula, a problem still seen too often due to lack of emergency obstetrical care.
In 2009, there were 1200 midwives in Ethiopia, making a ratio of one midwife to 57,000 people. By 2015, the number of midwives had increased to 7800, making the ratio of one midwife to 10,500 people, a significant growth from 2009. This can be attributed to the many training programs now available aimed at training midwives to increase the access to skilled birth attendants and health care professionals throughout the country.
The number of training institutions for midwives increased from 5 to 46 between 2000 and 2012, and there are now three different categories of midwives: bachelor’s degree midwives, diploma midwives, and accelerated midwives. The bachelor’s degree midwives go through four years of post-secondary training, the diploma midwives go through three years of specialized midwifery training, and the accelerated midwives have three years of nursing and one year of midwifery training. The first group of accelerated midwives graduated in 2012. Of the 46 training institutions throughout Ethiopia, 18 provide degrees and the rest provide diplomas. Today, all regions except for Gambella have midwifery training institutions.
One major goal of the expansion of these training programs is to station skilled midwives in rural areas, specifically having at least two at each health center throughout the country. This would be an incredible improvement and resource for the women living in rural areas that are lacking in skilled healthcare workers, especially considering that midwives can prevent 87% of maternal mortality.
This is due to their ability to perform comprehensive examinations on women directly after giving birth, the ability to identify problems such as hemorrhage, and the ability to administer effective medications. Midwives are involved in encouraging women to give birth in the health centers, where institutional delivery has increased from 10% in 2009 to 34% in 2014.
The main goal of the government of Ethiopia, in concert with other organizations, has been to decrease the maternal and infant mortality rates. The expansion of midwifery training programs and the quality of training received have greatly improved the quality of care for many women throughout Ethiopia. The expansion of midwives has allowed for knowledge about family planning to spread, and the use of contraceptives in 2017 was 35.7%, up from 29% in 2011. The 2005 abortion reform law gave midwives the legal ability to offer abortion services. Even though abortion is still highly stigmatized, many midwives have said that even if they would not personally provide abortion services, they would refer the patient to someone who would.
Overall, the increase in training and prevalence of midwives throughout Ethiopia has greatly contributed to a decrease in the maternal mortality and infant mortality rates. Even though the country still has a long way to go, a steady decrease has been seen that matches well with the many initiatives taken, much of which can be attributed to the success of midwives!
