Author: Taddese Alemu Zerfu(PhD) Post doctoral Fellow Is deployment of trained nurses to rural villages a remedy for the low skilled birth attendance in Ethiopia? a cluster-randomized controlled community trial . Author: Taddese Alemu Zerfu(PhD) Post doctoral Fellow

Conclusions Methods Results & Discussion Introduction Methods Results & Discussion Conclusions Maternal and neonatal mortality remains unacceptably high in SSA & SA Most could have been prevented with simple inexpensive, low-technology measures The single most critical intervention is the presence of a skilled provider during childbirth and the immediate postpartum/newborn period. Thursday, January 17, 2019

HEP and emerging limitations Introduction Methods Results & Discussion Conclusions HEP and emerging limitations HEW Contributed for ANC, PNC and FP But, often lack the time and skills to provide SBA and other essential skilled care services. The competency of HEW ? < 50% of the HEW knew signs of obstructed labor (Aray M.et.at) HEW are overwhelmed by 16 packages Thursday, January 17, 2019

Conclusions Methods Results & Discussion Introduction Methods Results & Discussion Conclusions Cultural, social and economic problems. Very low SBA &institutional delivery ; 27.7 % Vs 26% (National) 21% Vs 19% (Rural) A novel and culturally sensitive approach is urgently needed?  Could CORN fill this gap? Thursday, January 17, 2019

To determine the effect of CORN on SBA services utilization Introduction Objectives Methods Results & Discussion Conclusions To determine the effect of CORN on SBA services utilization To examine the programmatic and socio-cultural acceptability of home based delivery of SBA services Thursday, January 17, 2019

Study Area and period Introduction Methods Results & Discussion Conclusions Study Area and period The study was conducted in Gedeo zone of the SNNPR. SNNPR region makes 20% of national population. The study lasted for 18 months (from pre-implementation to final evaluation) Thursday, January 17, 2019

94 villages per arm = 282 villages randomly selected from 18 Kebeles Introduction Methods Results & Discussion Conclusions Study design A Three Arms Cluster Randomized Controlled Community Trial conducted in four phases. Arm one : CORNs based at HP and living with the community providing SBA. Arm two : CORNs based at HC level providing SBA and other RH services to households on an outreach bases. Arm three : randomly selected comparable controls clusters . Sample size : 94 villages per arm = 282 villages randomly selected from 18 Kebeles Thursday, January 17, 2019

RCT Intervention Home visit (CORN with HEW): Educate and Counsels pregnant/lactating mother (with the husband) on the need for health facility SBA /MNH services utilization and other related issues Mother (with husband) decided to use facility based institutional SBA services? Yes No Assess for Risk pregnancy that necessitates Hospitalized delivery ? E. g: Previous C/S scar, mother with cardiac problem...etc Facilitate Referral to HC/Hospital for ANC and SBA services + Counsels on birth preparedness Yes No Follow up visit every month (ANC visit time) to confirm use Re-counsel and reinforce mother for Hospitalized SBA Mother stick to the counseling decision and started facility level service utilization Counsel mother( and husband), they decided to use SBA/MNH services at home/health post level? Yes No Yes No STUDY INTERVENTION Encourage and honor mother/family for subsequent use Counsel mother on clean & Safe Delivery Close follow up CORN provides SBA and immediate post partum care at HH or HP level Thursday, January 17, 2019 Figure 1 : CORN Activities (INTERVENTION) Algorithm

Who are CORNs? Introduction Methods Results & Discussion Conclusions Female diploma nursing (midwifery) graduates from accredited HLI in Ethiopia. Passed intake exam Successfully completed a four months intensive skill oriented training on RH and Community health care activities. Recruited from both government health facilities and from the market after proper evaluation The trained CORN were deployed to work with rural HEW Thursday, January 17, 2019

Data Collection and Analysis Introduction Methods Results & Discussion Conclusions Data Collection and Analysis Data were collected at baseline, and end line of the project both (intervention and control) sites. Analyzed using SPSS V- 16 and EPI INFO V- 7 statistical software. Intention to treat analysis Proportions DID calculated Thursday, January 17, 2019

Introduction Methods Results & Discussion Conclusions Table 3.1. Utilization of SBA services and home delivery at baseline and end of the study in rural Gedeo, Southern Ethiopia Variable Control n ( %) CORN HP DID P CORN HC PP SBA at home Baseline End line 16 (3.1) 8 (1.7) 21 (3.8) 22 (5.2) 2.8 0.035* 34 (5.4) 6 (1.3) -2.7 0.078* SBA at HP 0 (0) 0(0) 179 (24.8) 24.8 0.001** 55 (7.8) 7.8 0.01* SBA at HI† 193 (26.9) 198 (27.7) 154 (21.7) 121 (16.8) -5.7 0.065 84 (11.7) 197 (27.9) 15.4 0.02* SBA Total 209 (30) 206 (29.4) 175 (25.5) 322 (46.8) 21.9 118 (17.1) 258 (37) 20.5 0.001 Non-SBA (Home)delivery 508 (70) 515 (72.3) 536 (74.5) 400 (53.2) -23.6 601(82.9) 474 (66.7) -18.5 0.03*

Introduction Methods Results & Discussion Conclusions Figure 3.1 : Proportion of skilled deliveries and non-skilled home deliveries at baseline and end line of the study in rural Gedeo, Southern Ethiopia

Introduction Methods Results & Discussion Conclusions CORN significantly contributed for SBA in general and HP & Home based in particular Compared to control, significant decline in home delivery at intervention sites Distance, perceived high quality, good approach of health workers and other unspecified reasons

Revitalize HEP for excellent and exemplary PHC services !!! Together ! Integrated! Diversified!