Community-Based Newborn Health Promotion in Pastoralist Ethiopia: The Social Mobilization and Demand Creation Project

"...this brief pilot study suggests that pregnant women are open to changing their health behaviors when they are encouraged and supported by local CVs [community volunteers]..."

In an effort to reduce newborn deaths (those in the first 28 days of life), Ethiopia has implemented a policy framework to support newborn health, reflecting the Every Newborn Action Plan (ENAP) approved by the World Health Assembly in May 2014. To support this, the United States Agency for International Development (USAID)'s Maternal and Child Survival Program (MCSP) funded a pilot project on Social Mobilization and Demand Creation [SMDC] for Improved Newborn Care in Errer Woreda, Somali Region, Ethiopia, from October 2015 to March 2016. CORE Group implemented the pilot, using the CORE Group Polio Project (CGPP) platform, led in Ethiopia by the Consortium of Christian Relief and Development Associations (CCRDA). This report documents the project, which tested a set of community-based activities to further the goal of lowering neonatal mortality.

The Government of Ethiopia's key newborn health promotion strategy is to include newborn care messages in the family health card (FHC). The card includes about 64 messages on health issues, which health extension workers (HEWs) and health development army (HDA) volunteers share with mothers and caregivers during counseling, either individually or in groups. (The package of services provided by HEWs includes environmental health promotion, family planning, immunisation, and maternal and child health (MCH) services. HDAs are female voluntary community workers who support HEWs through mobilising the community and providing selected health messages. The HDA is organised in such a way that a woman who adopts recommended health behaviours (by implementing the 16-plus health packages of the Health Extension Program, or HEP) - the network lead - is networked with five other women in the neighbourhood to disseminate the healthy behaviours and practices.) This strategy has been relatively effective in the agrarian regions of the country. However, there are no well-documented strategies or "best experiences" on promotion of newborn health in the more remote pastoralist and semi-pastoralist areas. Thus, the potential populations to be reached as part of the SMDC project included communities in the pastoralist areas of Ethiopia (Benishangul Gumuz; Dire Dawa; Gambella; Harari; Southern Nations, Nationalities, and Peoples' Region (SNNPR); Somali; and parts of Oromia), where HEPs and HDAs are almost nonexistent.

The Ethiopia CGPP developed the SMDC project by (i) reviewing existing government documents on demand generation and social mobilisation, (ii) conducting a planning workshop, and (iii) writing an implementation plan for the project. The programme strategy, developed during the planning workshop, was a generic one that can be adapted according to the development platforms used by partner agencies in the region. (It includes, for example, facilitating collaboration and consensus across the Ethiopian Federal Ministry of Health (FMOH) and non-governmental organisations (NGOs) currently implementing immunisation activities related to the CGPP in pastoralist areas.) Implementing partners - Hararghe Catholic Secretariat and Erer Woreda, located in Siti Zone, Ethiopia Somali Regional State - were selected for the pilot project based on the accessibility of the site, technical capacity, and flexibility of administrative systems to ensure adequate support and oversight of project activities.

To achieve outcomes in a short period of time (4 months), the project considered 2 overarching strategies: harmonisation of newborn care messages and use of community-based structures, including CGPP structures, traditional community structures, and formal government structures, to share and promote the selected newborn care messages. CGPP promoted implementation of maternal and newborn health (MNH) communication strategies and messages harmonised with government programmes and implemented in tandem with existing public services. The project kept most of the newborn care messages in the FHC as they were and added a few modifications to improve the language and pictures to better reflect the cultural and geographic contexts of pastoralist and semi-pastoralist areas. International and local NGOs leveraged their programme/community platforms to promote the adoption of healthy practices for women and newborns, tapping into the "parent power" advocated in the ENAP.

The project developed a project logic model that identified inputs, processes, outputs, outcomes, and impact. HEWs and community volunteers (CVs) were the 2 main cadres selected to deliver the newborn care messages to pregnant women and mothers. Project staff received training on a package of guides and materials related to the messages in November 2015, and in November and December of that year, they provided 3-day cascade training to 23 HEWs and 64 CVs. In addition, about 170 community stakeholders, including kebele and religious leaders, received an orientation to the project and key messages. These stakeholders visibly supported the volunteers during the project, and in some cases, they actually participated in village meetings and home visits. A series of supervisory activities supported project implementation.

The project used a mixed method, quantitative and qualitative assessment to measure predetermined project outputs and outcomes before and after implementation. During the quantitative phase of the assessment, the team reviewed records from the 3 health centres and 9 of the 14 health posts in the study and collected data on 7 MNH indicators. Sample results of the quantitative assessment:

• Health facility delivery rates doubled (from 7.1% to 14.2%), and registration of pregnant women quadrupled (from 7.4% to 30.0%) compared to pre-intervention rates, although both remained lower than desired.
• Nearly 3 in 5 women (59.3%) who were registered chose to receive antenatal care (ANC) services at a health facility.
• The same proportion (60.0%) received newborn counseling by CVs who visited their communities.
• More than half of all women (53.9%) who delivered in a health centre during the intervention period had previously been registered by the project (and encouraged to use these services).
• Overall, 1 in 4 registered pregnant women delivered in a facility centre, much higher than the average for the area, and probably a low estimate given the short intervention measurement period.
• Home-based newborn visits within 2 days of birth were quite limited, suggesting the many challenges of identifying and reaching newborns in a timely way among a low-literacy, remote, and mobile population.

During the qualitative phase, the project conducted focus groups discussions (FGDs) as well as in-depth interviews with HEWs, CVs, groups of mothers, and a group of community stakeholders.

• CVs said they considered their communication with HEWs, mostly through mobile phones and meetings, to be adequate.
• HEWs stated that this communication should occur more frequently, with the support of a more formal system of mobile phone communication.
• The main barrier to institutional delivery, according to CVs and HEWs, was limited transportation, particularly from the health centre to home after delivery.
• In addition to lack of transport and/or related costs, mothers who had recently delivered at home identified culturally based delivery traditions, perceived lack of quality of care at health facilities, and mother-grandmother influences as enablers of choosing home delivery.
• These women viewed the main benefits of CVs' activities as demand creation for ANC and child immunisation, exclusive breastfeeding, and newborn danger sign recognition.
• Health providers viewed the identification and referral of pregnant women in the community as CVs' most important contribution. Other benefits acknowledged were changes in the mothers' knowledge of danger signs, women's willingness to continue ANC without interruption, women's willingness to deliver at health centres, and women coming to the health centre for care and support when they identified a potential health problem.

Perhaps a key finding from the qualitative research: "In this study, participants identified the mother, supported by her husband, as the main decision-maker in seeking care for ill newborns. The rapid increase in the numbers and percentages of women registered, attending ANC, and seeking a facility-based delivery during this brief pilot study suggests that pregnant women are open to changing their health behaviors when they are encouraged and supported by local CVs in the community."

According to the authors, this study shows that community-based pregnancy surveillance can be achieved rapidly and effectively when it is integrated into established community-based immunisation delivery platforms. However, identification and registration of pregnant women does not always translate into service demand. In this project, there seems to be a gap of about 40% between those initially identified and registered and those who later received ANC and counseling on newborns.

They observe that problems with estimating pastoralist population size make it difficult to measure the actual number and proportion of women who are pregnant and in need of maternal and neonatal services. Thus, research is needed to: find ways to improve methods to track the changing population size and locations of pastoralist groups; more consistently provide timely local transportation for women who wish to deliver in a facility; and improve communication between health facilities and community-based CVs in order to increase postpartum care coverage in the home.