September 22, 2010

Making childbirth safer in Ethiopia

While conducting research for the Maternal and Newborn Health in Ethiopia Partnership (MaNHEP) over the summer, Emory 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 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. 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 because 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 workers will then share these practices with pregnant women, their families and traditional birth attendants, 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 by women and their family members. And 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 hemorrhaging. 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.

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 for 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.

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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