Getting there: Overcoming barriers to safe motherhood in Ethiopia
Many pregnant women in rural Ethiopia have a long way to go to reach a health facility where basic emergency obstetric care is available. However, research carried out by Jimma University in Ethiopia and the University of Ottawa, Canada, shows that cultural factors and service infrastructure may be as much to blame as poor road quality and long distances.
Although pregnant women receive support to deliver in health facilities with skilled attendants, the 2016 Ethiopia Demographic and Health Survey showed that fewer than 20% of women in rural areas take advantage of the services. In Jimma Zone, where the Ethiopian-Canadian research team worked, only 26% of women gave birth in a facility. This low attendance contributes to the country’s high rate of 353 maternal deaths per 100,000 live births and a neonatal mortality rate of 29 per 1,000 live births.
An enduring challenge: birth in health facilities
Although high, these figures are a vast improvement over 2003 rates, when the country’s flagship Health Extension Program was launched. During the interim, more than 16,440 health posts have been established that are staffed by two salaried and trained health extension workers. Their work is complemented by volunteer community health workers, who promote health services.
Since the flagship program’s introduction, access to family planning, antenatal care, HIV testing, and child immunization have improved. The rate of women giving birth in health facilities, however, shows little change. Progress in this area eludes health authorities despite measures like maternity waiting homes. Located at rural health centres, women in late stages of pregnancy can stay at these “homes” to be monitored for complications as they await the birth. The collaborative research project in Jimma Zone found that fewer than 7% of pregnant women used these maternity waiting homes in 2017, and 64% of those who did arrived only within 24 hours of delivery. These findings underscore the challenge the government faces in reducing maternal and neonatal deaths.
The Safe Motherhood Research Project, funded through the Innovating for Maternal and Child Health in Africa Initiative, is testing two measures to increase the use of maternal and child health services. The first is to upgrade the maternity waiting homes; the second consists of information campaigns to educate communities about the need for antenatal and postnatal care and the importance of a medically supervised delivery.
Improving the standards of maternity waiting homes
Providing fully operational maternity waiting homes is a key intervention because, as project co-lead Ronald Labonté at the University of Ottawa says, “These are supposed to be funded and supported through local communities, but in many cases, they simply haven’t been constructed or brought up to the standard that they should be. This becomes a barrier — women don’t want to go there because they’re not welcoming.” Women who stay at these homes share their experiences — whether good or bad — which in turn influences whether other women will use them.
As the researchers discovered, the maternity waiting homes varied markedly in terms of infrastructure, amenities, and services. Working with the Jimma Zone Health Office, the team identified 11 criteria these homes should meet to be fully functional, including continuous water and electricity supply and the presence of trained attendants to prepare culturally appropriate food for the women. Each of the 24 homes they assessed fell short.
The project upgraded eight randomly selected homes. “We had to get them up and running the way they were supposed to if they were going to make a difference in maternal and child health,” says Labonté.
Communicating for success
The researchers also found that women lack an understanding of the services, therefore they don’t perceive them as necessary. Health extension workers agree with this analysis: “If we can’t clearly explain the benefits, the women won’t come,” said one.
To boost community support for the use of health facilities and maternity waiting homes, the researchers developed communication tools to inform health extension workers, spouses, religious leaders, and community members in general about maternal and childcare and the benefits of giving birth in health facilities. As the Ethiopian research project leader Lakew Abebe points out, religious leaders and community health worker volunteers participated in implementing the two interventions tested, particularly the information and education campaigns, “because they have a great influence on community members.”
Voicing community norms, one religious leader stated, “I didn’t accept why [a woman] would stay there, leaving her family at home, if her delivery date is not reached.” This attitude was widespread among both men and women. Traditional gender norms, roles, and relations were evident in Jimma Zone, where many women surveyed felt that their place was in their home, particularly if they had other children. Sometimes husbands objected to them spending time away from their household responsibilities. In fact, researchers found that half the women depended on their male partner to make decisions: in 30% of cases, husbands even decided where their wives should deliver. Given their influence, involving men in the discussion was a priority.
The team is analyzing the data collected to assess the impact of their interventions and they are using video to document the use of maternal waiting homes. While the results are still being tabulated, monitoring indicates an increase in the number of women using the homes in project areas.
The researchers have seen that the success of these waiting homes and the use of other maternal and child health services depends on the active role of the community in endorsing them. Strong support from community leaders is expected to boost the use of maternal health services — in particular, the number of facility-based births — leading to better maternal and child health.