Ethiopia Fieldwork Experience

Tigist Mersha in front of MOH sign in Addis Abbaba.

Tigist (TG) Mersha is an MPH student in the Division of Community Health Sciences. TG is conducting her APE at the Ministry of Health under the Maternal and Child Health Depar in Addis Ababa, Ethiopia. TG is planning to survey the existence of preconception care education among 3 government hospitals to identify what tools they utilize to teach preconception and family planning education and further assess the needs of each of the selected facilities. She also is looking to develop a family planning toolkit/infographic in the native language (Amharic) for childbearing women to be distributed to healthcare providers that are partnered with the Ministry of Health.

I started my APE experience on June 12th at the Ministry of Health Ethiopia (MOH). During my first week here in Addis, my contact person, also my preceptor at MOH, welcomed me at the MOH office. My initial expectation when I came to do my APE was to join MOH’s preconception care planning team to develop and implement the document on various healthcare facilities, including government and private maternal hospitals. After joining the planning team, I hoped to collect a baseline survey from patients and providers on the access, utilization, and delivery of preconception care education in various maternity hospitals. However, after further conversation with my preceptor, I learned that the preconception care education program is still in the active phase, and the team at MOH is still not actively working on developing the program and document itself.

As a result, a new feasible approach to the project I want to do was to survey providers alone from maternity hospitals on their approach to educating women on preconception care education at their practice site. In order to do this, during my first week and a half here in Addis, I was in contact with the Addis Ababa Regional Health Bureau director and submitted a letter of intent to do my internship at government hospitals in Ethiopia. Out of three federal, four regional, and two maternity hospitals, I selected one government hospital, Zewditu, and two public maternity hospitals, Abebech Gobena and Gandi, to work with providers. All hospitals are well-known in the country and considered referral hospitals.

After finishing more paperwork and letters that needed to be signed and submitted to each of my selected hospitals from Addis Ababa Regional Health Bureau and Ministry of Health Ethiopia, my second and third week of APE was focused on developing baseline survey, connecting with the providers at each hospital and distrusting the survey, and lastly collecting the data using Qualtrics. Though I am still waiting on some responses from a few providers, I have noticed that the primary responses indicate that most government health center providers don’t give preconception care, mainly due to the lack of the program and guidelines from the Ministry of Health as it’s still in the works.

After seeing the preliminary responses, moving forward in my APE, I plan to survey a few providers (i.e., midwives and nurses) from a private maternity hospital on how they approach their preconception care education. This will compare the difference between government referral hospitals guided under the Ministry of Health and Addis Ababa Regional Health Bureau versus private sector maternal hospital approach to women’s health pre-pregnancy.

Though the project approach is slightly different from what I initially expected, I look forward to my APE experience in the coming weeks and learning more about the gaps within the Ethiopian healthcare system regarding maternal health.

My eight weeks stay at the Ministry of Health, Ethiopia (MoH) has ended. As I mentioned previously, I worked on my APE project on understanding access, delivery method, utilization, and gaps in preconception care (PCC) education among three government hospitals in Ethiopia. The significant finding through the self-administered pre-and post-surveys, usage of the toolkit, and observation of the facilities is that PCC program PCC education doesn’t exist in the current medical system in the country. Through my finding, it appears that a few of the hospitals stated giving PCC education to individuals who come to their family planning clinics, well-women visit, or gynecology appointments; however, they also note the fact that there is no formal guideline to guide them to speak to women about PCC topics when they come to these clinics and appointments.  

From the baseline survey finding, providers mentioned doing group health promotion once in a while, and 68% of these group health promotion educations are focused on family planning, sexually transmitted diseases, nutrition, preconception substance use, and pre-pregnancy medication use such as folic acid and iron intake. Still, while providers mentioned that they provide these educational contents to individuals when they seek care, most providers also admit that PCC education isn’t routine care, making it difficult for providers to recall to educate every individual who comes to their hospital unless there is a significant need. 

After the baseline survey, I gave providers a one-pager guideline/ toolkit on how and what to advise women about PCC. The toolkit included seven action points that providers must address when counseling women on PCC education, including family planning intentions and pre-pregnancy nutritional intake. The toolkit was developed using the MoH Obstetric Management Protocol guide, CDC, WHO, and other evidence-based studies addressing PCC education’s importance. Based on the observation of toolkit usage in the hospitals, most providers stated that such a toolkit on PCC is essential to improve the health care delivery of maternal and child health (MCH) in hospitals. In order to enhance MCH care in the country, a few recommendations from providers were suggested, including having all staff be trained on PCC education, having a dedicated clinic/program/department for PCC education, and having a dedicated team and leadership that monitors the implementations of such program in each hospital.  

In addition to determining the gaps in the PCC program, I also saw the immense need when it came to access more MCH hospitals throughout my internship. One of the observations that intrigued me was that one hospital I worked with has only eight delivery rooms and yet delivers 800-850 babies per month. Similarly, another MCH hospital delivers over 1000 babies monthly with limited delivery rooms as well. These hospitals mainly serve individuals of low socioeconomic status from all over the region of the country. Hearing about the number of monthly deliveries surprised me as I didn’t expect the extent of the service these hospitals provide. Seeing the staff, resources, and hospital shortage, I know we need to improve as a country to increase the quality of MCH care centers.

Still, while the country needs much more growth in delivering quality care for women and babies, it was also eye-opening to see that all government hospitals provide MCH care free of cost. In addition, I was intrigued to see a dedicated staff and space for an abortion care center in a government hospital for women who come for both unsafe and safe abortions.

Despite the challenges, I also saw several innovative and advanced methods when I attended the National Health Exhibition 2023 hosted in the country for the first time to improve the current MCH and medical care (see Gallery for further look on the exhibition and more). I saw current advanced methods, such as using a mobile ultrasound by home nurses, paperless medical data storage by community health workers (CHW), the first genetic testing center, and Electronic Medical Records (EMR). While improvements still need to be made in the country, these are a few new ways emerging to increase the health of individuals and communities. All in all, my internship at MoH and the hospitals was eye-opening and a great experience to see the culture, bureaucracy, weaknesses, and strengths of the country regarding MCH and general health care.