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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 2019

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 Overall Activities: 

At the beginning of the project late in the second half of 2017, the Principal Investigator and the Project Manager travelled to Seattle, WA, USA, to discuss key aspects of the project including the design of the project, management of activities and human resource and development of study tools. In addition, as part of the preparation for the project, the project team in Gondar was given training on development and use of electronic data collection tools by a graduate student fellow from the University of Washington (UW) brought through the Strengthening Care Opportunities through Partnership in Ethiopia (SCOPE) collaboration.

Following approval of the project by the University of Gondar (UoG) Institutional Review Board (IRB), The team conducted two of the initial preliminary studies: 1) Health facility assessment that focused on delivery and emergency obstetric and neonatal care activities of the health facilities in the project area, and 2) Formative qualitative study involving focus group discussions and key informant interviews with pregnant women and their partners, health workers and religious leaders to generate information on Maternal and Child Health (MCH).

Early in 2018, analysis of the formative qualitative study was completed and a report of the results was shared with regional and national authorities. Subsequently, results of the formative studies and summaries of the project progress were shared at international fora by the study team and UW student fellows. These included: 1) A scientific presentation in Seattle that won the Global Healthies Award, 2) A presentation at a scientific workshop and exhibition hosted by the UoG, 3) A presentation at a scientific forum in Accra, Ghana, and 4) Presentations in Seattle for the US collaborators and undergraduate and graduate students in the UW.

In preparation for the intervention phase, the project team developed Standard Operating Procedures (SOPs) for all the major activities of the project, and a training manual was prepared to guide the training of outreach workers (faith leaders and members of the Health Development Army (HAD)). Then a one-week training was given to 121 priests and members of the HAD recruited from the catchment areas of the six health centers selected as project intervention areas. The trained outreach workers were then dispatched to their respective communities to start the intervention activities.

Monitoring and evaluation of the outreach activities were done through regular follow-up group discussions with outreach workers in the 6 intervention areas conducted by the project team. These were coupled with regular health facility data extraction visits to all the 18 project areas (6 intervention sites and 12 control sites).

The project activities could not be completed in the initially proposed two years due to several reasons, the main one being the political situation of the country characterized by widespread public unrest and security-related problems affecting project implementation. So, by the end of the first two years, the project team applied for no cost extension of the project which was allowed by the PEER organizers.

The main activities in the first two quarters of the third year of the project (2019) were continuation of the intervention activities, monitoring and evaluation of the intervention activities and health facility data extraction. Problems encountered during the implementation of these activities were regularly discussed with the field workers, the project team in Gondar and the collaborators in Seattle, and solutions were set forth and implemented. The planned one-year intervention activities ended at the end of May 2019 marked by an official closing/handover ceremony with the involvement of local officials and stakeholder organizations, whereas the data extraction activities continued for some time beyond to complete missing data from some health facilities due to in country security-related problems and public unrest.

The participation of the UW student fellows in the project continued in the third year. During the year, one of the student fellows did her doctoral presentation back in the US on the work she had done with the team in Gondar. A team of people including SCOPE Board members from Seattle travelled to the project site in Gondar during which they visited one of the health facilities involved in the project, and had a meeting with the UoG study team to discuss project progress.

By the end of 2019, the project team had to request for further no cost extension of the project for three months into the year 2020, which was allowed by the PEER organizers. Early in this period, the project team was able to complete the initial data analysis and produce dissemination materials (reports to the Regional Health Bureau and the Ministry of Health, policy brief for policy-makers, summaries and presentation materials for local officials, partners and stakeholder organizations). However, the team was able to conduct the local dissemination activities, and further dissemination activities were put on hold because of the COVID-19 pandemic and the continued political situation of the country.

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