1. S YSTEMATIC DOCUMENTATION OF COMMUNITY - ORIENTED APPROACHES TO IMPROVE RECOGNITION OF AND APPROPRIATE CARE SEEKING FOR NEWBORN AND MATERNAL COMPLICATIONS A Case Study of the Maternal and Newborn Health in Ethiopia Partnership Presenter Dr. Lynn Sibley

2. Overview Maternal and Newborn Health in Ethiopia Partnership (MaNHEP) MaNHEP Case Study – Overview Aims Questions Design and setting Methods – Presenters Panel discussion

3. 3.5 year Learning Project (2009-2013) Demonstrate community-oriented model of maternal & newborn health care for birth & early postnatal period Bill & Melinda Gates Foundation-funded Ministry of Health, Emory University, John Snow Research & Training, University Research Co, LLC, Addis Ababa University, local communities

4. Project Sites 3 woredas (districts) in each of Amhara & Oromiya regions Vertical “slice”of each district’s health system Total population est. 350,000, ~12,000 births per year

5. Action Theory

6. CMNH Care Package WomanNewborn Care at Delivery Clean delivery Uterotonics Uterine massage Postnatal health assessment Color check Activity check Feeding check Helping babies breathe Postpartum health assessment Breast check Bleeding check Trauma check Fever check Counseling Breastfeeding Thermal care Hand washing & cord care Illness care seeking Counseling Breast care Nutrition, hygiene, rest Uterine massage Illness care seeking At 90% coverage, package has been shown to reduce newborn mortality 38% Darmstadt et al. 2005 At 90% coverage, package has been shown to reduce newborn mortality 38% Darmstadt et al. 2005

7. Objectives Every woman & newborn… in time… every time Improve FLW capacity to provide CMNH care Increase demand for CMNH care & improve self-care practices Develop model districts that are capable of continuously improving CMNH service delivery

8. Intervention Components CMNH Training Behavior Change Communications Collaborative Improvement

9. Important Results Substantial improvements in frontline workers… – Completeness of MNH care provided – Demonstrated ability /confidence to provide MNH care – Sense of being part of a MNH care team Substantial improvements in women’s…. – Awareness of and trust in frontline health workers’ ability to provide MNH care – Completeness of care they received

10. Important Results (cont.) Successful solutions for pregnancy identification, ANC registration, labor-birth notification and PNC follow-up adopted across the 51 project kebeles Substantial improvements in women’s use of skilled providers and health extension workers for antenatal and postnatal care A small, but significant shift towards use of providers with a higher level of skill for birth care (differed by region)

11. Indicator % of women who received birth care Amhara Region Oromiya Region Baseline (n = 493) Endline (n = 479) Baseline (n = 534) Endline (n = 540) Health facility 617 a 1214 Skilled provider 718 a 1314 HEW 319 a 11 9 CHDA<1 2 b 3 10 a TBA1238 a 28 47 a Family / other unskilled7723 a 46 20 a a P <.001, b P <.05 Shift in Use of Birth Attendants

12. Factors Associated with Having a Skilled Attendant at Birth Factor Odds Ratio 95% Confidence Interval Region (Amhara versus Oromiya) 2.241.64, 3.07 a Education (versus none) Any primaryNS Any secondary or higher4.071.68, 9.89 b Antenatal from skilled provider or HEW 2.871.73, 4.76 a CMNH Family Meetings ( >2 versus <2) AloneNS With Family1.811.31, 2.51 a Antenatal & CMNH Family Meetings ( >2) 5.22.9, 9.4 a a P <.001, b P <.05

13. Indicator # days between 175 perinatal deaths, Cohort of pregnant women enrolled March 2011 through February 2012 Shift noted ~ 12/20/11 An Encouraging Pattern… CMNH Family Meetings & QI begin ~ 03/01/11

14. The MaNHEP Case Study Aims Questions Design Mixed methods Presenters

15. Specific Aims To provide understanding of the MaNHEP project context To gain a more nuanced understanding of current community and/or cultural factors that facilitate or impede illness recognition, decision-making and care-seeking for maternal and newborn complications in the original MaNHEP area

16. Questions How did the MaNHEP project influence care seeking among families who reported having experienced a pregnancy-related complication between 2010 and 2012?

17. Questions (cont.) How did the MaNHEP project influence the decision-making process and sequence of care seeking among families who experienced a maternal or newborn complication during birth or within 28 days of the last birth, two years-- after the field activities ended?

18. Questions (cont.) Were there regional differences in illness recognition, decision-making and care seeking for maternal and newborn complications? – Are these similar to differences observed in 2012 for care seeking in the case of normal labor and birth?

19. Design and Setting Embedded case study Original MaNHEP project districts Random sample of PHCU facilities – Referral hospital (1) – Secondary hospital (1) – Primary hospital (1) – Health centers (6) – Health posts (12)

20. Mixed… Methods, Researchers, Lenses Desk review Secondary data analysis MNH program inventory Health facility mapping Illness narrative

21. Presenters Secondary data analysis – Dr. Lynn Sibley MNH program inventory – Mr. Mulusew Lijalem Belew – Mr. Kemeredin Shifaa Health facility mapping – Dr. Solomon Tesfaye Illness narrative – Dr. Yared Amare