JIJIGA, 13 August 2010 (IRIN) - When Safi Mukhtar had her first baby, she never considered going to a hospital or clinic for the delivery. Faced with some of the world's worst maternal mortality statistics, the Ethiopian government hopes that next time, she will think differently.

Childbirth will prove fatal for one in 27 women in Ethiopia and much of the rest of the continent, according to the UN Children's Fund (UNICEF), versus a rate of one in 8,000 in industrialized countries.

"Giving birth at home is like a tradition; it is mainly the difficult [pregnancies] that we take to the hospital," Muktar told IRIN in Kebribeyah village, south of Jijiga, in the eastern Somali region. "For example, if a woman goes into labour at 4pm and by 8pm she has not given birth, we will take her to Jijiga [40km away]."

Cultural norms, low education levels and poor health infrastructure limit the number of women giving birth in a medical facility to about 5.3 percent, as well as reducing contraceptive use, another factor in maternal mortality.

Just 6 percent of births in Ethiopia take place in the presence of a skilled health professional, according to the 2005 Ethiopian Demographic and Health Survey (EDHS), the most recent survey of its kind; the next one is due in 2010.

The same survey states that for every 100,000 live births, 673 women died.

"Women [tend to] deliver at home, where there are delays in diagnosing problems," Premila Bartlett, the senior reproductive health and family planning adviser for the US Agency for International Development (USAID) in Ethiopia, told IRIN.

"Delays in identifying obstetric emergencies, in getting the woman to the health facility and in getting the services at the health facility all combine to result in maternal death."

In many parts of the country facilities for comprehensive obstetric care are non-existent.

Amina Seid, 26, from Awshashit village in the northern Afar region, told IRIN she had relied on a traditional attendant for all but her last birth. She only went to hospital after being treated for fistula, a hole in the birth canal caused by prolonged and obstructed labour.

"It is the cut that is making me suffer up to now," Seid, a mother of six said, referring to female genital mutilation/cutting (FGM/C), a common practice that increases the risk of complications during childbirth.

Access problems

"There is recognition that women are delivering at home and there are many reasons for this," Patricia McLaughlin, of IntraHealth International in Ethiopia, said.

"Women don't come in that early for pregnancy check-ups; they also do not really talk about being pregnant [in the early months]. Distance is also a big issue, if you are busy; you have to take the day off to go to the clinic.

"The problem for women is not just getting to the health centre but also getting back home," noted McLaughlin adding that awareness creation is key as without the right expertise "you cannot really tell in advance who is going to have an 'at risk' pregnancy".

But before creating demand for clinical childbirth facilities through public information campaigns, she said, it was essential to put such facilities in place.

"Maternal health is not where [as developed as] people want it but it is improving," she added, noting that a lot of attended deliveries were being supported by health extension  workers.

Some 34,000 health extension workers are now deployed in rural areas. They "are trained in clean delivery but not considered skilled attendants. They are also not the [older] traditional midwives, so there are credibility issues," noted USAID's Bartlett. "The pay is also not that great, they may make more money farming but they like the skill, the status..."

Contraception issues

Although the workers are trained in the use of a subcutaneous contraceptive rod that lasts two years, contraceptive use remains low.

"More than seven in 10 women who want to avoid pregnancy either do not practise contraception or use a relatively ineffective traditional method. These women can be said to have an unmet need for modern contraception," stated a July report by the Guttmacher Institute and the Ethiopian Society of Obstetricians & Gynaecologists.

"Expanding contraceptive use is... crucial to limiting women's exposure to the general risks inherent in pregnancy and childbearing and to enabling women to avoid high-risk births in particular."

Such a message is a hard-sell in some parts of the country, such as the Somali region, where just 9 percent of women said they had had an "unintended" pregnancy, against a rate of 72 percent in the capital, Addis Ababa.

"Having only a few children or controlling birth is not something we like. We don't want to stop giving birth because then the husband can go and get a new and young wife," Fadumo Dayib, a Jijiga resident, told IRIN. "Children also assist with farming and taking care of the animals. When one gets more children one gets more resources."

More women want to space their births than to stop childbearing altogether, noted a 2008 Ethiopian Society of Population Studies report. The report also noted that kin support systems and the authority of clan leaders in regions such as Afar, Somali, Gambella and Benishangul Gumuz to ostracize those "who try to alter the high values attached to procreation" encouraged large family sizes.

In areas with limited health services, a woman who loses a child is more likely to conceive again, or at least try to.

"Family planning is a key pillar of safe motherhood," said USAID's Bartlett. "It is a tool, [but] not [for] one and all as women will still want to have babies, and [some] will develop complications, thus the need for emergency obstetric care at the lowest levels."