In a recent training in Bahir Dar, Lamesgin Alamineh (left) and Mulu Hailu (right), MaNHEP maternal and newborn health specialists, demonstrate proper care for a newborn to a health extension worker.

The scenario is familiar to many health extension workers (HEWs) in rural Ethiopia. A pregnant woman living in a remote village wakes up one morning bleeding. She does not suspect anything is wrong and continues working. With the bleeding worsening the next day, she tells her family who has to find money for transportation to a health center. The woman eventually receives medical care, but later dies from excessive bleeding.

Determining how her death may have been averted is among the exercises that HEWs are tackling in training workshops led by MaNHEP. Beginning this summer, the Community-Based Maternal and Newborn Health (CMNH) Training Program uses a participatory, skills-based approach to teach participants about a package of home-based lifesaving practices that can help prevent maternal and newborn death and disability, such as clean delivery and essential care in the immediate and early postnatal period for mothers and newborns. Over the next 18 months, MaNHEP aims to get more HEWs and other frontline health workers, such as community health volunteers and traditional birth attendants, to deliver this package to women and their families.

MaNHEP training activities are designed around a cascade approach. Small groups of HEWs will initially be trained. Later, these same HEWs, with support from MaNHEP, will lead training activities for other frontline health workers in their communities. By the end of the project, more than 19,000 "birth teams" will emerge from the program, benefitting an equal number of pregnant women.

The CMNH process builds on local knowledge and skills through discussions, demonstrations, negotiations, and practice, with the goals of gaining acceptance by the participants and increasing the likelihood that the skills and knowledge will be used. The process is empowering and creates bonds among program facilitators, women, and families. Trainers use culturally appropriate visuals to teach concepts which are brought to life through hands-on simulations.

Each year in Ethiopia, an estimated 22,000 women die from causes related to childbirth and an additional 100,000 newborns die. Most of these deaths occur at home, due to lack of basic health care. If successfully brought into the home, the basic package of home-based care practices, such as keeping babies warm, dry, and breastfed, can reduce maternal and newborn mortality by up to one-third.

Bosena Melese was among the first group of HEWs trained in Bahir Dar. Like many of her colleagues, Melese had limited classroom training and practical experience in maternal and newborn health. "Previously, I knew very little about how to deliver babies," said Melese. "Now I can help save the lives of mothers and newborns."

Melese credited the hands-on aspect of the MaNHEP workshop for strengthening her skills and confidence to deliver maternal and newborn health care. "We learned from practicing the demonstrations and talking about what happened," she said. "Now I'm eager to pass on the information to others."

Sandy Buffington, a MaNHEP training consultant, likened the skills that HEWs gain to those delivered in emergency rooms during childbirth, such as administering fluids for shock prevention. "They experience the process of childbirth and learn how to be prepared for the most common complications that they may encounter," she said.

Melese and others are clearly benefitting after only one week of training. In assessments conducted before and after several workshops, MaNHEP found a 70 percent improvement in skills across the board.

"It was thrilling to see the HEWs get excited about what they were learning and tell us of their intention to share the information with other frontline health workers," said Associate Professor of Nursing Maureen Kelley, MaNHEP technical lead for process monitoring. "This training is going to make a difference in saving the lives of mothers and newborns."

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Researchers Look for Ways to Make Childbirth Safer in Ethiopia

	Jed Stevenson (center), an Emory University anthropology doctoral student, explains survey techniques during a research training in Amhara. He is flanked by Emory undergraduate student Yemesrach Tadesse (left) and Assistant Professor of Anthropology Craig Hadley (right).

While conducting research for MaNHEP over the summer, Emory University public health student Catherine Finneran made an unsettling finding. “When we asked mothers how many children they had, they would consistently tell us that they had a certain number of live children and a certain number who they had lost during childbirth,” said Finneran. “Sadly, death of children is a part of life here.”

More than 100,000 newborns die each year in Ethiopia, many within the first 48 hours after delivery. MaNHEP aims to change this statistic through a community-oriented program designed to bring lifesaving maternal and newborn health (MNH) services into the home. As part of this effort, Finneran and eight other Emory University students, led by faculty members Craig Hadley and Rob Stephenson of the Department of Anthropology and School of Public Health, respectively, took part in surveys of more than 1,000 adult women and frontline health workers in the Amhara Region to understand patterns of childbirth and attitudes towards MNH services. The data will be used to shape and assess interventions to improve maternal and newborn survival.

In Ethiopia, more than 90 percent of childbirths take place in homes with the aid of only family members or traditional birth attendants (TBAs). Ethiopia’s fledgling Health Extension Program is designed to bring health services, including MNH care, closer to where people live. The effort, however, has been stymied by the facts that health extension workers (HEWs) receive limited training in MNH care and people don’t understand their value or roles.

“It’s a self-sustaining cycle,” explained Hadley. “HEWs haven’t received enough training to feel confident in providing MNH services, while women and families don’t see them as having roles in pregnancy and delivery, and therefore do not seek them out.”

MaNHEP is working on three fronts to break down the barriers limiting the delivery of MNH services. Training activities for HEWs and other frontline health workers will focus on building skills and confidence to deliver a basic home-based package of interventions, including clean delivery and essential care in the immediate and early postnatal period. These individuals will then share these practices with pregnant women, their families, and TBAs, with the goal of building "birth teams" trained in MNH care. Using behavior change communications, MaNHEP will also seek to increase demand for MNH services on the part of women and their family members. Finally, quality improvement activities will focus on strengthening MNH systems by addressing barriers to care.

One of the biggest risks to women during childbirth is excessive post-partum hemorrhage. In their research, Emory anthropology students Jed Stevenson and Yemesrach Tadesse found that women typically associate this event with spirit possession and address it by cracking a whip, shooting a gun into the air, or making a loud noise. “Part of our intervention is to provide the correct information about labor and delivery,” said Hadley. “We want them to understand that excessive bleeding is an emergency requiring transport to a health facility.” 

Embet, a 20-year-old mother of three from a small village where MaNHEP works, knows firsthand the consequence of excessive bleeding during delivery. Several years ago, a woman in her community died because of complications from post-partum hemorrhaging caused by placenta retention. Embet, who is pregnant with her fourth child, said she plans to deliver at home, but understands the importance of contacting an HEW should complications occur.

MaNHEP is working to build awareness among more women like Embet of the need to have a plan for childbirth. Emory researchers found that most families already make at least some preparations for safe childbirth. This includes acquiring clean razor blades to cut the umbilical cord and soap to prevent infection. MaNHEP’s challenge, said Hadley, is to figure out how to build on what women are already doing and provide them with a network of support through their communities to ensure safe delivery.

At the end of the project, Hadley expects to find changes in attitudes, priorities, and practices, around MNH services. “We know that delivery can be dangerous in Ethiopia,” said Hadley. “Hopefully, our follow-up research will reveal that more mothers are taking steps to make childbirth safer.”

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Quality Improvement Teams Tackle Barriers to Maternal and Newborn Health Care

	Solomon Tesfaye, MaNHEP quality improvement advisor, reviews pregnancy data supplied by a quality improvement team.

MaNHEP has formed pilot quality improvement teams in Ethiopia’s Oromia Region to address barriers that may prevent women and newborns from obtaining care.

“We’re essentially applying a collaborative process improvement approach that the business community uses to increase efficiency,” explained Lynn Sibley, director of MaNHEP and associate professor at Emory's School of Nursing. “In this context, we’re working with those on the frontlines of delivering maternal and newborn health services to have them identify barriers, develop solutions, and test those solutions.”

The quality improvement teams, consisting of frontline health workers and community leaders, are initially focusing on pregnancy registration and birth notification. Such systems are essential to ensuring all women and newborns receive the basic package of maternal and newborn health care during the period from birth to 48 hours later when they are most vulnerable.

Ideas that are being tested include using volunteer community health workers and designated households to capture data on pregnancies and births in their communities. MaNHEP staff are meeting regularly with the teams to discuss outcomes of their implementation efforts.

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