IntroductionEthiopia introduced national Maternal Death Surveillance and Response (MDSR) in 2013 and is among the first sub-Saharan African countries to capture data on facility-based and community-based maternal deaths. We interviewed frontline MDSR implementers about their experiences of the first 2 years of MDSR, including perceptions of its introduction and outcomes for health services.MethodsWe conducted a qualitative case study in 4 zones in the largest regions, interviewing 69 key informants from regional, zonal, district and facility levels.ResultsA defining feature of Ethiopia's MDSR system is its integration within existing disease surveillance, with both benefits and challenges. Facilitators of the system's introduction were strong political support, alignment with broader health strategies and strong links across health system departments. Barriers included confusion around new responsibilities, high staff turnover and fear of legal repercussions. Stakeholders believed MDSR increased confidence in using local data to improve maternal health services and enhanced communication across the health system.ConclusionsMDSR systems take time to establish, encountering challenges in early implementation. Ensuring MDSR has a clear purpose, explicitly defined roles and responsibilities, and adequate supervisory support from the start will ensure it becomes embedded within the health system as routine practice rather than perceived as a stand-alone system. Countries planning to adopt or extend MDSR can learn from Ethiopia's experience, particularly the decision to make maternal mortality a weekly reportable condition within Public Health Emergency Management.

BackgroundHealth systems often fail to use evidence in clinical practice. In maternal and perinatal health, the majority of maternal, fetal and newborn mortality is preventable through implementing effective interventions. To meet this challenge, WHO’s Department of Reproductive Health and Research partnered with the Knowledge Translation Program at St. Michael’s Hospital (SMH), University of Toronto, Canada to establish a collaboration on knowledge translation (KT) in maternal and perinatal health, called the GREAT Network (Guideline-driven, Research priorities, Evidence synthesis, Application of evidence, and Transfer of knowledge). We applied a systematic approach incorporating evidence and theory to identifying barriers and facilitators to implementation of WHO maternal heath recommendations in four lower-income countries and to identifying implementation strategies to address these.MethodsWe conducted a mixed-methods study in Myanmar, Uganda, Tanzania and Ethiopia. In each country, stakeholder surveys, focus group discussions and prioritization exercises were used, involving multiple groups of health system stakeholders (including administrators, policymakers, NGOs, professional associations, frontline healthcare providers and researchers).ResultsDespite differences in guideline priorities and contexts, barriers identified across countries were often similar. Health system level factors, including health workforce shortages, and need for strengthened drug and equipment procurement, distribution and management systems, were consistently highlighted as limiting the capacity of providers to deliver high-quality care. Evidence-based health policies to support implementation, and improve the knowledge and skills of healthcare providers were also identified. Stakeholders identified a range of tailored strategies to address local barriers and leverage facilitators.ConclusionThis approach to identifying barriers, facilitators and potential strategies for improving implementation proved feasible in these four lower-income country settings. Further evaluation of the impact of implementing these strategies is needed.

Background: Triangulating findings from MDSR with other sources can better inform maternal health programs. A national Emergency Obstetric and Newborn Care (EmONC) assessment and the Maternal Death Surveillance and Response (MDSR) system provided data to determine the coverage of MDSR implementation in health facilities, the leading causes and contributing factors to death, and the extent to which life-saving interventions were provided to deceased women.Methods: This paper is based on triangulation of findings from a descriptive analysis of secondary data extracted from the 2016 EmONC assessment and the MDSR system databases. EmONC assessment was conducted in 3804 health facilities. Data from interview of each facility leader on MDSR implementation, review of 1305 registered maternal deaths and 679 chart reviews of maternal deaths that happened form May 16, 2015 to December 15, 2016 were included from the EmONC assessment. Case summary reports of 601 reviewed maternal deaths were included from the MDSR system. Results: A maternal death review committee was established in 64% of health facilities. 5.5% of facilities had submitted at least one maternal death summary report to the national MDSR database. Postpartum hemorrhage (10-27%) and severe preeclampsia/eclampsia (10-24.1%) were the leading primary causes of maternal death. In MDSR, delay-1 factors contributed to 7-33% of maternal deaths. Delay-2, related to reaching a facility, contributed to 32% & 40% of maternal deaths in the EmONC assessment and MDSR, respectively. Similarly, delay-3 factor due to delayed transfer of mothers to appropriate level of care contributed for 29 and 22% of maternal deaths. From the EmONC data, 72% of the women who died due to severe pre-eclampsia or eclampsia were given anticonvulsants while 48% of those dying of postpartum haemorrhage received uterotonics. Conclusion:The facility level implementation coverage of MDSR was sub-optimal. Obstetric hemorrhage and severe preeclampsia or eclampsia were the leading causes of maternal death. Delayed arrival to facility (Delay 2) was the predominant contributing factor to facility-based maternal deaths. The limited EmONC provision should be the focus of quality improvement in health facilities.

To overcome the shortage of blood to treat obstetric hemorrhage, the first step is to evaluate the demand and supply gap by acquiring comprehensive data on the current status of the blood supply and the prevalence of obstetric hemorrhage in Ethiopia. Subsequent steps would include the implementation of transfusion policies, the optimization of whole blood collection, ensuring quality-assured testing of donated blood, and the implementation of transfusion guidelines for the appropriate use of blood products. Strategies for long-term, viable solutions to maintain an adequate blood supply should be simultaneously developed.

In recent days, it is common to see increasing incidence of Fanconi, proximal kidney tubular damage and chronic kidney diseases-CKD among high risk populations that drew the clinicians’ attention to monitor closely. Among these risk populations with potential CKD incidence; HIV positive patients who uses TDF as a component of HAART need to be monitored for the incidence of CKD as a toxicity of TDF before initiation and during treatment despite the fact that the current monitoring practice in Ethiopia in most hospitals remain to be poor. Hence this study aimed at measuring the incidence of CKD among high risk segment of HIV positive pregnant and lactating women who uses TDF as part of their HAART treatment. Using a non-proportionate stratified sampling, a total of 111 HIV+ pregnant and lactating women who are on TDF based HAART treatment were enrolled to measure the incidence of CKD based on NKF K/DOQI Classification. Using the Android application of Medicalc GFR-cg, and MDRD-4; the prevalence of stage-2 CKD was 16.2 % (60-89 ml/min) and Stage 5-CKD/Renal Failure who require dialysis were 3.6% (CrCl < 15ml/min/1.72m2) by both method of calculation CrCl (GFR-cg and MDRD-4). Women who were lactating had a relative risk of 0.918 (95% CI lies within 0.845-0.998) of acquiring CKD (P= 0.045). The other associated factors were BMI less than 18.5 (P= 0.004 and adjusted OR of 7.82), WHO clinical stage-1 (P=0.014, odds ratio of 5.4 and 95% CI of 1.24-24.42), baseline CD4 count > 500 (P=0.02), and duration on TDF (> 12 months on treatment) and low haematocrit of 30 had a higher risk of falling into Stage 2 CKD with cohort risk estimate of 4.103 (95 % CI of 1.02, 16.54). The risk estimate of WHO stage 2 to acquire stage-4 CKD was 1.087 (95% CI of 1.002, 1.180) statistically significant (P=0.05.). The prevalence of stage 2 CKD among pregnant and lactating women by GFR-cg method of calculation was higher than MDRD-4 calculation. In this study, MDRD-4 method underestimated stage 2 CKD. Hence it is worth and highly recommended to use GFR-cg method in the baseline and during treatment monitoring of TDF toxicity to the kidney particularly for diagnosing the early stage of CKD.