Early effects of family conversation on institutional
deliveries, early postnatal and newborn care practices in
rural Ethiopia:
A propensity score-matched analysis
International SBCC Summit
February 8, 2016
Addis Ababa
Presentation outline
• Background
The Health Extension Program and L10K interventions
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• Study:
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Methods and analysis
Results
Conclusions
Lessons learned and recommendations
Background: Ethiopia
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High maternal mortality ratio (353/100,000 live births)
Stagnating neonatal mortality rate (28/1,000 live births)
Low skilled delivery care and early postnatal care coverage
In early 2014, L10K introduced ‘family conversation’ to promote institutional deliveries,
early postnatal care and immediate newborn care practices
• Objective: To examine the early effects of ‘family conversation’ on institutional deliveries,
early postnatal and newborn care practices in rural Ethiopia
Ethiopian Healthcare Delivery System
Specialized Hospital
(3.5 -5 million People)
General Hospital
(1-1.5 million People)
Primary Hospital: 100,000-200,000
Rural Health Center: 15,000 - 25,000
Rural Health Post: 3,000- 5,000
20-30 HDAs teams
150 1:5 Networks
Ethiopian Primary Healthcare System
Health Center
Health
Post 1
Health
Post 2
Health
Post 3
Health
Post 4
Health Development Teams
(25 HDA teams)/ kebele
Health
Post 5
The Last Ten Kilometers Project
• Implemented by JSI Research & Training Institute,
Inc., with grants primarily from the Bill & Melinda
Gates Foundation and with additional funding
from UNICEF and USAID
• The aim is to improve high impact
reproductive maternal, neonatal and child
health (RMNCH) care practices among rural
households and contribute towards Ethiopia’s
government effort for achieving child and
maternal health related MDGs 4 and 5
L10K’s Platform
• 17 million people in 115 woredas (districts)
• Enhance the skills of HEWs to provide community-based maternal, newborn,
and child health (MNCH) services
• Community-based data for decision making for targeted services
• Anchors HDAs in local institutions to sustain volunteerism
• Family conversation
• Birth notification
• Strengthens linkages within PHCUs
– Regular supportive supervision; and
– Woreda-level review meetings
Family Conversation
• A family level dialogue at the pregnant woman’s home where her husband, mother inlaw, and her neighbors attend the conversation to engage and take roles in
supporting her during pregnancy, labor and postpartum periods
• The session is usually facilitated by HEWs and in some cases by HDAs
• Intervention: two sessions of family conversations conducted at a pregnant
woman’s home
• Follows three steps of discussion - exploration, discussion and joint planning
Family Conversation Guides
Methods
• Cross sectional survey data was used to compare programmatic outcomes between
those who reported having had family conversations during their last pregnancy and
those who did not
• The outcomes were reported practices associated with the most recent childbirth
among women with children 0-11 months
• Cross-sectional data from 3,883 women with children 0-11 months from 324
kebeles (communities)
Analysis
• Propensity score match (PSM) analysis used to estimate average treatment effect
• Propensity score matching variables: socio-demographic characteristics of the
respondents (age, education, marital status, parity, age of youngest child, religion,
duration living in the area, distance from drinking water source, distance from a health
facility, household wealth), number of antenatal care visits during the most recent
pregnancy, administrative regions, and the implementation strength of other L10K
strategies in the kebele
• Treatment effect: the weighted average differences in the outcome variables between
exposed and not-exposed PSM pairs or groups
Prevalence of selected MNCH practices in
115 districts of L10K areas, 2011 and 2015
2011
100
93
2015
90
76
80
83
70
60
30
55
45
50
40
55
53
51
37
28
20
26
9
10
10 10
0
Received ANC
4+
institutional took clean cord received PNC Took thermal
delivery
care
in 2 days
care
Baby put to
Exclusively
breast within breast fed baby
an hour after
delivery
% of women who reported that family
conversation was conducted, 2015
Activities
%
Family conversation conducted by (N= 3,883)
None
83.8
HEW with or without HDA
12.0
HDA only
4.2
Family conversation participated by (N= 635)
Husband
79.5
Mother-in-law
15.5
Mother
28.5
Other family members
19.6
Neighbor
16.7
Effects of Family Conversation
MNH Indicator
Family Conversation
Effect (95% CI)
Received
Did not receive
Institutional delivery
61.8
55.0
*6.9(2.0, 11.7)
PNC in 48 hours
18.6
7.6
*11.0(4.1, 18.0)
Clean cord care
40.3
36.5
Thermal care
64.8
53.5
*11.4(4.3, 18.5)
Initiating breastfeeding immediately after
birth
67.5
66.0
1.6(-5.4, 8.6)
Exclusively breastfed
97.0
92.1
*Statistically significant effects (p<0.05)
3.8(-6.9, 14.5)
*4.9(2.2, 7.5)
Conclusions
Family conversation improved coverage of institutional delivery, PNC with in 48 hours,
thermal care and exclusive breastfeeding
Lesson Learned and Recommendations
• Household members who are also caregivers and major decision-makers, especially
husbands and mother-in-laws, should be part of the target audience for behavioral change
communication (BCC) to improve maternal and newborn care seeking behavior and
practices
• Although the family conversation was effective, its coverage was low
• HEP should seek strategies to improve the efficiency of reaching the target audience with
similar BCC messages