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Cycle 5 (2016 Deadline)

Improved access and uptake of maternal and child health services in rural Ethiopia through collaborative community and health systems partnership

PI: Getahun Asres Alemie (, University of Gondar
U.S. Partner: Judd Walson, University of Washington
Project dates: December 2016 - December 2018

Project Overview:

In 2015, the average Ethiopian woman had a 1 in 64 lifetime risk of death due to complications of childbirth, and 87,414 newborns died before their 28th day of life. Reducing maternal and neonatal deaths has been at the top of the global health agenda for more than a decade and was recently included in Goal 3 of the Sustainable Development Goals (SDGs). Demand for maternal, newborn, and child health (MNCH) services, however, still remains low in Ethiopia’s rural communities most at risk. Complex challenges, including transportation, health literacy, imbalanced decision-making authority, and harmful traditional practices, create barriers to increasing health coverage.

This implementation science study will utilize an integrated delivery approach to increase demand for MNCH services in the Gondar region of Ethiopia. The research design aims to address primary drivers of maternal and neonatal death, including access to antenatal care, prevention of mother-to-child transmission of HIV (PMTCT), facility-based delivery, and postpartum visits through a culturally driven lens. The goal of the project is to improve MNCH outcomes in rural Ethiopia by increasing demand for services through the linkage of local health workers and community influencers. The study team will collect and analyze qualitative data to establish a baseline for women’s engagement with their health facilities, identify barriers to accessing MNCH services, and parse out traditional practices and beliefs around childbirth and infant health, including religious rituals. From the baseline information, a behavior change intervention will be implemented in which community leaders from the Ethiopian Orthodox Church will be paired with members of the Health Development Army (HDA) and trained to conduct maternal and child health outreach and education. Strategies for transporting laboring and postpartum women to health facilities will be devised and implemented by the local communities. The study team will develop a clear monitoring and evaluation plan at the outset of the study, including tracking time to seeking care, frequency of seeking care, removal of barriers to care, and measures of morbidity and mortality. The study hypothesis is that there will be an increase in demand for MNCH services following the intervention, with targeted increases in the uptake of antenatal care, PMTCT, facility-based delivery, and postnatal care and referral. It is expected that the impact of increased engagement with health facilities will decrease maternal and neonatal deaths in the study population compared to the control group.

Summary of Recent Activities: 

As of December 2017, the University of Washington’s Strengthening Care Opportunities through Partnership in Ethiopia (SCOPE) sent technical support in the form of a graduate student fellow to assist in the development of the mobile data collection tool (OpenDataKit or ODK) and train the study staff to develop and maintain the database for this tool. After the ODK training and the development and piloting of the FLAME tools, the research team completed facility assessments to gather baseline information about delivery and emergency obstetric and neonatal care provided at randomly selected health centers in the North Gondar zone. They assessed 30 randomly selected health centers and collected data regarding antenatal follow up size, facility delivery size, maternal and child health capacity of health centers, emergency and referral services. A final report of the data is completed and the University of Gondar study team has outlined a manuscript for publication that will highlight key findings from this assessment. The team conducted 12 focus groups discussions (FGDs) and five key informant interviews (KII) to obtain important information from pregnant women, their partners, religious leaders, health extension workers and health center heads to inform the design of the intervention in order to ensure acceptability of the intervention to be implemented in the second year. The semi-structures facilitator guides for the qualitative work included themes around barriers to antenatal care, common birth practices, influencers in decision-making for birth, and receptiveness to health messages from faith leaders. Using the data found from qualitative work, we will adapt a training curriculum for priests and health development army workers who will then be sent out to the community to educate and change behavior around seeking care to increase antenatal care and facility delivery in the study area.

Currently, the FLAME team is in the process of completing their final component of the formative work before launching the intervention: surveys with women of reproductive age. The surveys will allow them to gleam further insight into current community practices about childbirth and perceptions about safety and comfort of giving birth at facilities and/or at home.
The team administered the surveys at churches in randomly selected catchment areas of the North Gondar Zone. To date we have completed 58 surveys at two sites. There are four more site visits planned to reach their goal of 280 total survey participants by mid-March 2018.
The FLAME study team randomized health center catchment areas into intervention and control groups in December 2017 and is beginning preparations (developing training tools, protocols, and recruitment of participants) for the intervention. The team expects training to occur in April 2018 that will mark the beginning of the intervention phase.

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