With a $350,000 one-year grant from Pfizer, the International Rescue Committee (IRC) will work to reduce maternal and neonatal mortality resulting from low utilization of skilled birth attendance (SBA), post-natal care (PNC) services, and family planning (FP) services, in the BGRS. This work will specifically focus on women in the woredas (third-level administrative divisions of Ethiopia) of Bambasi and Assosa. With Pfizer support, the IRC will equip mother-child pairs and their families with mama's mastawesha, a Color-Coded Health Calendar (CCHC), and will equip health workers with solar-charged tablet-based pregnancy, FP, and immunization 'Health Hinters,' basically automated databases enabled with a mobile Short Message Service (SMS) reminder system. A total of 107 health posts, which serve as satellite sites for the communities, will be equipped with 3 mobile phone units, and of these the 50 posts staffed by trained nurses will receive a tablet and training.
The Color-Coded Health Calendar (CCHC), using colors and pictures, highlights future antenatal care (ANC) visits, contingency travel dates to a health facility in case of complications or at-risk status, the delivery date, PNC visits, timeframe for commencing FP, and dates for early childhood immunizations. With support from Health Extension Workers (HEWs) and Community Health Volunteers (CHVs), women will use the CCHCs to discuss and make decisions with their families about pregnancy, their birth plan, and FP options post-delivery, and also become better educated on the immunizations critical for their children in their first years of life. Color-Coded Health Calendars prompt more holistic planning and decision-making for health involving other household decision-makers such as husbands, mothers, and particularly mothers-in-law. As visual, pictorial tools, CCHCs cater to low literacy populations improving comprehension and learning. In addition, compared to the ANC cards currently distributed at health facilities, CCHCs promote greater active engagement between CHVs and family members while also serving as personalized cue cards due to the built-in reminder mechanism when used in conjunction with the Health Hinter platform.
To complement the client-level CCHCs, Health Workers will be equipped with a variety of resources and training by the IRC. Solar-charged tablet-based 'Health Hinters' for health posts will serve as automated registries of mother-child pairs in the area. Compared to current paper-based systems, the Hinters will be programmed to automatically send SMS messages to HEWs/CHVs mobile phones, reminding them about upcoming ANC, PNC, FP and immunization appointments (either at the facility or community level1). HEWs/CHVs will reply via SMS to confirm a visit took place and will also have the ability to alert the health post about an emergency case, such as an incoming client requiring emergency obstetric care. Solar-charging capabilities for tablets and phones will address unreliable electricity while still quickly connecting health service providers with their clients. The automated database software for the tablets and reminder mechanism has already been developed and the IRC team is in the process of developing proto-types of the CCHC.
Deliverable 1: Equip and empower pregnant women and their families to make timely decisions about seeking health services during pregnancy, childbirth, post-natal periods, including FP and immunization, as prompted by the CCHC.
Phase I: Development of Materials and Community Engagement and Sensitization Activities
December 2013 - January 2014: Develop CCHC and provide to mother-child pairs in Bambasi and Assosa during first provider-client contact. Develop and print pregnancy registers for health posts.
-Evaluate project metrics pre-intervention.
IRC will evaluate the project through establishing a baseline at the beginning of the project using routine data of the previous year; and a final evaluation using a routine data that will be maintained during the course of project implementation.
Phase II: Training
January - February 2014:
-Train HEWs, CHVs and TBAs on use of CCHC and their roles in promoting consistent and effective use.
-Provide 1-day refresher orientation, per Federal Ministry of Health protocol, for 204 HEWs and 2,040 CHVs in the woredas of Bambasi and Assosa on newborn visits, immunization, FP and referral.
January - November 2014: Work with TBAs/CHVs and community leaders across both woredas to encourage newborn referral and home visit compliance in the community.
Phase III: Service provision/implementation
January - November 2014: Facilitate discussions with targeted women/their families on SBA, newborn care, FP, immunization and CCHC use. CHVs/TBAs visit and encourage women using CCHCs to be prepared to travel to facilities before delivery date by following birth plan and to adhere to post-natal, FP and immunization appointments.
December 2013 - February 2014: Equip health facilities in both woredas with clean delivery kits and FP commodities.
December 2013 - November 2014: When required, support health facilities logistically to have vaccines by transporting them from RHB to the woredas and ultimately, to health facilities.
Deliverable 2: To connect mother-child pairs and skilled service providers by equipping 50 health posts with automated 'Health Hinter' tablets and HEWs/CHVs across 38 kebeles (neighborhoods) with mobile phones.
Phase I: Adaptation of software and procurement of tablets and phones
December 2013 - January 2014:
-Adapt software to: track pregnancies and newborns as well as appointments for FP and immunization, populate centralized CCHC registry and automatically send SMS to CHVs/HEWs regarding household visits and upcoming expected delivery and appointment dates.
-Purchase and provide solar-powered tablets to 50 health posts to run the automated CCHC registry and solar-charged mobile phones to HEWs/CHVs across 38 kebeles in Bambasi (5 phones/kebele used by workers on-duty).
Phase II: Training
January - February 2014:
-Train 50 nurses/HEWs on effective use of the tablets and management of the automated CCHC registry and SMS reminder system; train HEWs/CHVs to send SMS to the automated CCHC registry concerning when a visit to a pregnant woman has been completed, serving as a counter referral.
-Orientation for 2,040 CHVs, 204 HEWs and 500 TBAs on the use of CCHC, on their role, new born visit, immunization appointments, family planning and referral
Phase III: Service provision/implementation
January - November 2014:
-Confirm health post readiness to receive pregnant women for delivery and PNC services as well as for FP and immunization services via HEWs/CHVs home visits.
-Promote greater collaboration between HEWs and CHVs/TBAs during weekly meetings by using information from the automated CCHC registry to identify, discuss and plan for upcoming household visits/one-to-one health promotion.
-Measure project metrics with full implementation of project.
The Benishangul-Gumuz Regional State (BGRS) of Ethiopia has the highest neonatal and perinatal mortality rates in Ethiopia, with 62 deaths per 1,000 live births and 58 deaths per 1,000 live births, respectively. According to the Ethiopia Demographic and Health Survey, neonatal mortality accounts for 42% of deaths in children under 5 years-old. Major causes of neonatal mortality include sepsis, asphyxia, premature birth, and neonatal tetanus. Having access to appropriate maternal and neonatal care plays a crucial roles in reducing neonatal mortality. With proper peri-natal care, many cases of neonatal sepsis and asphyxia can be prevented. In addition, only 8.9% of deliveries in the region are conducted by a skilled provider.
While the reasons for low utilization of available maternal and newborn services are complex many of these issues can be addressed with a proactive intervention. Currently, major barriers to care utilization include factors that lead to delays in seeking, reaching and receiving quality maternal and newborn care services. These factors include low awareness concerning the importance and availability of certain health services and poor health seeking behavior of the mothers. Women also face a lack of autonomy and support from families including husbands; generally husbands serve as the head-of-household and their permission and support is required for many actions. As mobile phones are common among community members, this technology serves as a potential method for reaching out and engaging mothers and their families to participate more fully in their healthcare. Currently, mobile phones are not being used for healthcare purposes, but the model proposed under this initiative could serve as a platform for future projects. Other barriers to healthcare include cultural practices, financial difficulties, distance to reach health facilities, and the shortage of skilled man power and inadequate medical supplies available at health facilities.