Establishing the Ethiopian Obstetric Surveillance System (EthOSS): building a regional network to monitor severe outcomes of pregnancy

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Background: Despite efforts by the United Nations and many governments around the world to reduce the number of women who die during pregnancy and around childbirth, 295 000 women still died during pregnancy and childbirth in 2017, 99% of whom in low- and middle- income countries (LMIC), particularly sub-Saharan Africa. In Ethiopia alone, around 14 000 women died the same year (highest number following Nigeria, India and DR Congo) and it appeared that the national maternal mortality ratio had even increased from 353 to 401 per 100 000 live births in the course of two years. Efforts to reduce maternal deaths and disability in Ethiopia are hampered by lack of reliable data. In order to develop targeted interventions and measure progress towards achieving the sustainable development goals, there is an urgent need to institute robust registration of maternal mortality and morbidity, and collect associated data to assess quality of care. Such registrations and enquiries were previously found to contribute importantly to the reduction of maternal deaths in the UK and other high-income countries. Objectives: establish a regional Ethiopian Obstetric Surveillance System (EthOSS) network to monitor severe maternal complications in twelve maternity units in Eastern Ethiopia and examine feasibility to implement a national EthOSS network in Ethiopia.Methods: This project involves four inter-related activities: 1) establishing a regional network and EthOSS consortium, 2) case registration on specific severe maternal outcomes, as defined by the consortium, 3) collection of detailed management data for confidential enquiry into one selected condition, and 4) establishing criteria for feasibility of a national EthOSS consortium and network.In the first phase (2-3 months), we invite all potential stakeholders (federal ministry of health, professional societies, community representatives and participating facilities) to take part in the network consortium. Under the leadership of College of Health and Medical Sciences, Haramaya University, Ethiopia, and the National Perinatal Epidemiology Unit (NPEU), University of Oxford, UK, a regional start-up meeting will be held, during which reporting criteria for mortality and morbidity are chosen. In the next phase (6 months), nominated clinicians at each of the twelve participating maternity units will report cases (including maternal deaths and cause of death) from selected conditions into a secure REDCap database. EthOSS researchers will confirm cases by visiting reporting units. Additionally, more detailed management items pertaining to cases from one condition (to be determined during the start-up meeting) will be collected to assess quality of case management for that condition by performing confidential enquiry. At the end of six months, quality of the EthOSS database and reported information will be evaluated by the consortium. A detailed review/confidential enquiry of cases from the priority condition will lead into a regional report on that condition. The final three months, feasibility of scaling up surveillance to national level and perceived challenges will be evaluated. Based on this evaluation of feasibility, the network will write a larger grant proposal in order to initiate a national EthOSS network, in close collaboration with the federal ministry of health, national professional organizations and client representatives.Expected outcomes: The possibility to introduce a regional, simple but robust registry of severe maternal complications in an LMIC in sub-Saharan Africa is examined for the first time. This will help to determine the burden of maternal mortality and other severe complications in the region. Use of detailed management data and confidential enquiry will generate evidence on quality of obstetric care and identify opportunities for improvement. Finally, a package of feasibility criteria for national surveillance is created.