URC and Emory University Celebrate Achievements in Improving Maternal and Newborn Health in Ethiopia with Partners

Last week, the Maternal and Newborn Health in Ethiopia Partnership (MaNHEP) presented project results and celebrated achievements at a dissemination meeting in Addis Ababa. Led by Emory University and funded by the Bill & Melinda Gates Foundation, MaNHEP sought to improve maternal and newborn health care in rural Ethiopia using a community-oriented approach. Emory University contracted URC to support Ministry of Health staff in the community and facilities as well as other community members in six woredas (districts) in Amhara and Oromia Regions to use quality improvement techniques to improve care for mothers and newborns.

The 2011 Ethiopian Demographic and Health Survey (EDHS 2011) reports a maternal mortality ratio of 676 per 100,000 live births and a newborn mortality rate of 37 per 1000 live births. Many of these deaths occur within the first 48 hours after birth and could be averted with access to basic health care. The MaNHEP project focused on building the skills of frontline health workers—in Ethiopia called health extension workers (HEWs), community health workers (CHWs), and traditional birth attendants (TBAs)— and supporting them to improve the systems needed to deliver quality maternal and newborn health care around the time of birth.

URC collaborated with Emory University to create and support quality improvement (QI) teams, which are comprised of kebele-level volunteers, including kebele administrators, women’s association members, elders, and religious leaders. (A kebele, or neighborhood, is the smallest administrative unit in Ethiopia.) QI teams were supported by MaNHEP and health sector staff to identify and test ideas to ensure that mothers and newborns receive quality care in and around the time of birth. MaNHEP also supports the QI teams to periodically meet during peer-to-peer learning sessions to share their results so that appropriate ideas would rapidly spread among all teams.

A mother holds her healthy newborn outside her home in rural Oromia. Photo credit: Nathan Golon, MaNHEP.

The project also sought to improve the knowledge and skills of pregnant women and their family caregivers—and frontline health workers—in basic, essential maternal and newborn health care. The participatory training was implemented through community maternal and newborn health (CMNH) family meetings. The QI teams support this effort through pregnancy identification, pregnancy registration and antenatal care, attendance at CMNH family meetings, labor/birth notification, and postnatal care visits within 48 hours of birth.

Key accomplishments of the QI teams include:

Increasing Pregnancy Registration: Effective pregnancy registration helps expectant mothers to receive proper care throughout pregnancy, labor and delivery, and immediately after birth. QI teams promote the importance of pregnancy registration through community organizations, religious and social gatherings, and coffee ceremonies as well as by targeting mothers-in-law and husbands. The teams then test various strategies to improve registration until they find approaches that work for their community and then scale up these approaches.

By using local expertise and social networks, MaNHEP’s QI teams reached a high and sustained level of performance for pregnancy identification and antenatal care (ANC) registration. Between November 2010 and December 2012, MaNHEP communities identified more than 21,000 pregnant women, and as of December 2012, 86.4% of newly identified pregnant women registered for ANC.

A pregnant woman in her third trimester receives a prenatal exam from a health extension worker. Photo credit: Nathan Golon, MaNHEP.

Improving Postnatal Care (PNC): Due to the country’s high rate of maternal and newborn illness and death and because postnatal care visits occur in less than 10% of births, the Ministry of Health prioritized PNC. By the end of December 2012, 41.8% of expected births were reported in project-supported districts. In addition, HEWs were notified within two days of labor/birth in 84.7% of reported births, and 83.5% were visited by HEWs within two days after delivery. PNC visits by HEWs within two days after birth increased from 1.4% of expected births in November 2010 to 34.9% by December 2012.

As the project comes to a close this month, MaNHEP is disseminating its results and tools. One important tool is the “change package,” an organized summary of strategies and solutions that have been locally tested and proven to improve care. MaNHEP developed the package by working with the QI teams and other stakeholders to categorize the changes that led to improvements in pregnancy identification, ANC registration, CMNH family meeting attendance, labor and birth notification, and PNC visits within 48 hours. Presenting concepts and successful solutions in a way that illustrates changes that improved CMNH care delivery in similar settings, the package can serve as a learning tool for other woredas and kebeles. It will be available for others to guide their work in improving care and will be paired with the CMNH Family Meeting package.

Quality Improvement in the MaNHEP Project
One of health care's great challenges is that while the knowledge of what interventions can help save lives is very advanced, the ability to actually implement these interventions is sorely limited. QI is a management approach that gives frontline workers the skills to develop and test strategies that would enable them to reliably use evidence-based interventions as needed. QI enables people to use the knowledge of their local environment along with their creativity and intelligence to come up with solutions that are appropriate in their context. URC has over 30 years of experience applying QI to health care and has demonstrated that significant improvements in health care quality are attainable in even the most resource-constrained settings. 
Frontline health workers demonstrate maternal and newborn care practices.
Photo credit: Nathan Golon, MaNHEP.
Building Peer-to-Peer Learning Networks to Improve Care
MaNHEP's peer-to-peer learning sessions have provided an excellent forum to support QI teams. Participants include representatives from the project kebeles, coaches from the woredas and health centers, zonal administration representatives, a woreda administrator, woreda health office heads, health center heads, and representatives of regional health bureaus. During such sessions, participants discuss their successes and challenges in improving pregnancy identification and registration, attendance at community maternal and newborn health family meetings, labor and birth notification, and postnatal care visits by HEWs. Through the sessions, teams find new ways of looking at the problems that prevent the delivery of quality care, learn about solutions that have worked for other teams, and leave with renewed confidence that they can improve care.

For more information on MaNHEP, see http://www.nursing.emory.edu/manhep/.

Smiling woman
A pregnant woman waits to be seen at a health post in Amhara Region. Photo credit: Nathan Golon, MaNHEP.
May 06, 2013
Magee McDonald, URC Project Coordinator; Dr. Solomon Tesfaye Abebe, URC Quality Improvement Advisor; and Dr. Lynn Sibley, Professor, Nell Hodgson Woodruff School of Nursing, Emory University
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