The Maternal and Newborn Health in Ethiopia Partnership (MaNHEP), implemented between November 2009 and May 2013, was designed to address the country’s high levels of maternal and newborn mortality. The project’s goal was to demonstrate a community-oriented model of maternal and newborn health (MNH) care in rural Ethiopia and to position it for national scale-up. The project sought to increase the capacity of frontline health workers, increase demand for newborn and maternal healthcare, and develop and demonstrate the effectiveness of districts to improve MNH.The intervention led to increased use of MNH services and improved perinatal outcomes. TRAction is supporting a case study to identify the facilitators and barriers to skilled care-seeking for maternal and newborn complications within the context of the MaNHEP project.
Ethiopia: Amhara and Oromiya Regions
This case study aims to understand the facilitators and barriers to care seeking for maternal complications. Research questions include:
This case study used both qualitative and quantitative methods to assess the program’s impact on recognition of maternal complications and skilled care seeking. A desk review was conducted to examine the program’s context and implementation, which included an inventory of existing MNH programs and a survey of implementation documents. Existing data from end-line surveys was used to identify the factors influencing illness recognition and care seeking. Qualitative data was gathered in the form of small group interviews with affected adult women and families, which provided information on the factors influencing illness recognition, the decision-making process, and care seeking in the face of maternal and newborn complications.
The narrative interviews show that mothers and their caregivers do recognize signs of illness such as a large amount of blood, continuous bleeding, blood clots and the co-occurrence of loss of consciousness, lethargy, headache and fever as illness symptoms and indicators of severity; or inability to feed, vomiting and diarrhea or lethargy in the case of the newborn. However, maternal bleeding of limited duration or a newborn that is unable to breastfeed, in the absence of other symptoms, may not be interpreted as a serious condition. In cases of maternal complications, close family members and neighbors participate in the decision to seek or not to seek care at health facilities, although the woman experiencing a complication or her husband often may make the final decision. In cases of sick newborns, a broader group of participants appear to be involved in the decision to seek care including their mothers, fathers, grandparents and aunts, although mothers or mothers and fathers jointly often made the final decision to seek care. Once a decision is made to seek care, various types and sequences of care are possible, including home or community-based, or public and private sources of care. A number of individuals are involved in referral; however, midwives and nurses are key participants. Findings show that health workers and TBAs also can play an important role in encouraging care seeking through the counseling they provide.
The findings of this case study highlight the need to further strengthen awareness of danger signs and risks of both maternal and newborn complications as well prompt and appropriate care seeking. Messages on these issues should address local explanations and treatment for illnesses. They should also target mothers and fathers, preferably jointly, and other members of the family and community. Future research is needed into the antecedents of referral decision-making—apart from explanatory models of illness and illness recognition-- that may lead to more nuanced and targeted health messaging. It is also essential to continue to enhance physical access to care by strengthening community sources of appropriate medications and care and improving transportation for women and newborns. Equally, if not more important, there is a strong need to strengthen the quality of care by improving both health workers’ skills and also their attitudes towards those they care for.
Ethiopia is making great progress in improving maternal and newborn health services, yet maternal and newborn mortality and morbidity remain unacceptably high. The FMoH has sharpened its focus and has introduced important new initiatives to strengthen MNH programming within the government health system to increase both the supply of and demand for care. Some of these efforts have incorporated elements from the original MaNHEP project. This case study identified the factors influencing care seeking for maternal and newborn complications. Results will be shared with various stakeholders, including the Ethiopian Ministry of Health and Regional Health Bureau officials. TRAction will synthesize the findings from this and four other recognition studies in order to facilitate understanding of community-oriented approaches for improving recognition of and care seeking for maternal and newborn complications. Experience from this study will be used to inform the development of community-oriented approaches for addressing maternal and newborn health in low and middle-income countries.
Principal Investigator: Lynn Sibley