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The Maternal and Newborn Health in Ethiopia Partnership (MaNHEP) is a three-year project to demonstrate a community-oriented model for improving maternal and newborn health care in rural Ethiopia. It is based at Emory University's Nell Hodgson Woodruff School of Nursing and supported by the Bill & Melinda Gates Foundation. Partners include:

This newsletter showcases MaNHEP's activities in training, research, and quality improvement. For more about MaNHEP, visit here.

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  Winter 2011

Quality Improvement Teams Address Barriers to the Delivery of Maternal and Newborn Health Care

When 28-year-old Yeshinat Atinkut found out she was pregnant with her third child, she only told her husband, mother-in-law, and neighbors. News of her pregnancy didn’t reach her village’s health extension worker (HEW) for six months.

A quality improvement team creates a flow chart of the pregnancy registration process.  

In rural Amhara, Ethiopia, pregnant women typically only reveal themselves to family members and neighbors. They may be resistant to telling health workers out of suspicion or lack of trust. If complications arise during pregnancy and childbirth, this can put mothers and newborns at risk of death or disability. Similarly, an unknown pregnancy limits a community’s ability to coordinate and deliver maternal and newborn health (MNH) care.

As part of its effort to bring MNH care to more women in rural Ethiopia, the Maternal and Newborn Health in Ethiopia Partnership (MaNHEP) is working with communities to strengthen those systems needed to deliver such care. In recent months, MaNHEP held the first in a series of quarterly learning sessions on the use of a healthcare improvement model for improving pregnancy registration and birth notification in Amhara and Oromiya Regions. More than 200 representatives of quality improvement (QI) teams, including community members, health care workers, district health managers, and kebele (village) leaders, attended the sessions, which focused on the concepts of QI methodology using practices and exercises.

For their initial work, QI teams consisting of 12-15 people are meeting monthly in their kebeles to devise “change ideas” for improving pregnancy identification. Outside the town of Merawi in Amhara Region, a QI team is initially testing the idea of door-to-door canvassing as a way for identifying pregnant women and linking them with MNH care. Depending on whether the team can reach its goal of 10 women in the first month, the team will continue to test the idea or try an entirely new approach and repeat the testing cycle.

QI teams may test different change ideas, depending on the barriers to improvement they encounter in their kebeles. For instance, in Amhara Region, one QI team is observing women at water fetching holes to see if pregnancies can be identified, while another team is testing whether “spiritual fathers” for households can be reliable sources of information on pregnancies.

“This training emphasizes teaching communities to identify their own problem areas with respect to maternal and newborn health systems, develop their own solutions, and monitor the results themselves,” explained Kim Ethier, MaNHEP senior quality improvement advisor. “Traditionally, efforts to improve quality of care focus only on health care facilities. A unique aspect of this project is that it is working with communities to improve the care provided in both communities and facilities.”

MaNHEP’s QI model follows a series of structured Activity Phases beginning with identification of the aims of the improvement work and followed by an action learning cycle to rapidly test ideas that are likely to lead to successful improvements (the Plan-Do-Study-Act or PDSA cycle). Solutions that are tried and implemented (as well as those that do not work) are documented and analyzed to ensure that successful MNH practices will be disseminated. QI coaches, who are MaNHEP advisors and specialists, regional health bureau staff and HEW supervisors trained in QI methodology, meet regularly with QI teams to help problem solve, inform them of best practices developed by other teams, and provide technical support in the implementation of activities.

“We expect an evolution to take place in how the teams develop their change ideas,” said Ethier. “As time goes on and members start working better as a team, ideas for overcoming barriers to improvement should become more targeted and creative.”



Teams Deployed to Strengthen Maternal and Newborn Health Care at the Household Level

  A guide team in rural Oromiya Region practices resuscitating a newborn.

Before completing a recent MaNHEP workshop, traditional birth attendant Nitsuh Awoke acknowledged that she wasn’t always sure what to do when complications arose during labor and delivery. “If a mother was bleeding, I would dig a hole in her house and put her over the hole,” she said. “Now I know to massage the uterus and refer her to the health post.”

Awoke learned about uterine massage and the importance of referral for complications through MaNHEP’s Community Maternal and Newborn Health (CMNH) Training Program, which focuses on building skills and confidence to deliver a basic package of home-based care practices that can prevent maternal and newborn death and disability. As part of the rollout of the CMNH program, MaNHEP has been training Awoke and other frontline health workers to serve as guide teams for their communities in safe delivery practices. The goal of the effort is to bring MNH care to more women in rural Ethiopia.

After identifying pregnant women in their communities, the guide teams assemble groups of people with whom these women have close contacts and can assist with delivery planning, including husbands, family members, and neighbors. These individuals comprise a “birth team” and receive CMNH training from frontline health workers, as well as supplies to be used during delivery in the event that a mother gives birth at home. Guide teams meet regularly with birth teams to ensure understanding of the MNH care package and address any issues associated with preparing for childbirth. Over the course of the MaNHEP project, birth teams will assist an estimated 19,000 pregnant women with safe delivery in Amhara and Oromiya Regions.

“Our aim is to initially equip the guide teams with the knowledge, skills, and demonstration materials associated with the MNH care package,” said MaNHEP Deputy Director Abebe Gebremariam. “They will then share what they’ve learned with the birth teams in their communities who will encourage mothers to seek out care during birth and the immediate postnatal period.”

For many frontline health workers, the CMNH training is their first opportunity to practice skills and techniques needed for safe delivery.

“The training really increased my confidence to provide MNH care,” said health extension worker Asmaku Kassa. “The skills and knowledge we gained will go with us. We’re going to take it to the next step.”

In implementing the CMNH program, Gebremariam said that MaNHEP has balanced the importance of skillsbuilding for those frontline health providers who most commonly assist with delivery with the importance of ensuring that all deliveries are eventually handled by skilled birth attendants, such as midwives and nurses. This approach adheres to the Ethiopian Ministry of Health’s policy that skilled birth attendants be the primary providers of clean and safe delivery services and that mothers and newborns are referred to health facilities when needs arise.



Addis Ababa University Strengthens Research Capacity Through MaNHEP Partnership

A research partnership between MaNHEP and Addis Ababa University-School of Public Health (AAU-SPH) to understand maternal and newborn health (MNH) practices in rural Ethiopia has helped to lay the ground work for more large-scale, public health studies in Ethiopia.

Last summer, AAU-SPH graduate students oversaw data collection for two MaNHEP studies, the findings of which will be used to assess project interventions for improving the delivery of MNH services in Ethiopia’s Oromiya Region. The work included door-to-door surveys and interviews of women of reproductive age, adult men and women, and frontline health workers in 30 villages of three districts. Findings appear in the MaNHEP Formative Research Study and MaNHEP Baseline Survey.

“This was the first time that we were involved in surveys this complex,” said Ayele Belachew, AAU professor of public health who served as the institution’s lead faculty member on the research. “The skills that were developed helped build our capacity to conduct similar studies in the future.”

AAU-SPH students underwent a weeklong training led by Belachew and Emory University faculty and graduate students that included overviews of MaNHEP’s research goals, the study design, and descriptions of data collection. The training also included the ethical principles for human subjects research and interviewing skills, such as techniques for probing respondents to capture as much information as possible.

Desalegn Wirtu was one of the eight AAU-SPH students who supervised the data collection. He credits the research methodology that he learned with inspiring his own dissertation research on adolescent sexual risk taking.

“My work with MaNHEP really helped me to visualize what I want to do as far as my own research,” said Wirtu. “I understand better now how to conduct research like this on my own, in particular how to work with communities in collecting data.”

In addition to the skills that the students built, Belachew believes their work fostered a greater understanding of the public health challenges facing Ethiopia. “Students should have knowledge about the communities where they will be working,” he said. “The information that they collected about maternal and newborn health practices will be valuable to them as future public health professionals.”

AAU’s partnership with MaNHEP will continue to develop as the project interventions unfold. Midway during implementation and towards the conclusion of the project, follow-up studies will be conducted to determine if changes have occurred in maternal and newborn health practices by women and frontline health workers.

“The MaNHEP studies were a learning process for our students, but they showed real confidence,” said Belachew. “This project laid the foundation for future research collaborations. It also gave us a new focus on maternal and newborn health.”

A new interdisciplinary program funded by the National Institutes of Health/Fogarty International Center will provide additional opportunities for collaboration between Emory University and AAU. Through the Emory-Ethiopia Global Interdisciplinary Training Partnership, doctoral and postdoctoral students from Emory and AAU will work on innovative research initiatives related to global health. Key aims are to foster sustainable multidisciplinary research between the two universities and translate research findings into practice.



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