Effects of family conversation on health care practices in Ethiopia: a propensity score matched analysis.

BACKGROUND: Maternal and newborn mortality rates in Ethiopia are among the highest in sub-Saharan Africa. The majority of deaths take place during childbirth or within the following 48 h. Therefore, ensuring facility deliveries with emergency obstetric and newborn care services available and immediate postnatal follow-up are key strategies to increase survival. In early 2014, the Family Conversation was implemented in 115 rural districts in Ethiopia, covering about 17 million people. It aimed to reduce maternal and newborn mortality by promoting institutional delivery, early postnatal care and immediate newborn care practices. More than 6000 Health Extension Workers were trained to initiate home-based Family Conversations with pregnant women and key household decision-makers. These conversations included discussions on birth preparedness, postpartum and newborn care needs to engage key household stakeholders in supporting women during their pregnancy, labor and postpartum periods. This paper examines the effects of the Family Conversation strategy on maternal and neonatal care practices. METHODS: We used cross-sectional data from a representative sample of 4684 women with children aged 0-11 months from 115 districts collected between December 2014 and January 2015. We compared intrapartum and newborn care practices related to the most recent childbirth, between those who reported having participated in a Family Conversation during pregnancy, and those who had not. Propensity score matched analysis was used to estimate average treatment effects of the Family Conversation strategy on intrapartum and newborn care practices, including institutional delivery, early postnatal and immediate breastfeeding. RESULTS: About 17% of the respondents reported having had a Family Conversation during their last pregnancy. Average treatment effects of 7, 12, 9 and 16 percentage-points respectively were found for institutional deliveries, early postnatal care, clean cord care and thermal care of the newborn (p < 0.05). CONCLUSION: We found evidence that Family Conversation, and specifically the involvement of household members who were major decision-makers, was associated with better intrapartum and newborn care practices. This study adds to the evidence base that involving husbands and mothers-in-law, as well as pregnant women, in behavior change communication interventions could be critical for improving maternal and newborn care and therewith lowering mortality rates.

Effects of a community-based data for decision-making intervention on maternal and newborn health care practices in Ethiopia: a dose-response study.

BACKGROUND: Community participation and community health volunteer programs are an essential part of the health system so that health services are responsive and accountable to community needs. Information systems are necessary for community health volunteer programs to be effective, yet effectiveness evaluations of such information systems implemented at scale are rare. In October 2010, a network of female volunteers with little or no literacy, the Women's Development Army (WDA), was added to extend Ethiopia's Health Extension Program services to every household in the community. Between July 2013 and January 2015, a health management information system for the WDA's Community-Based Data for Decision-Making (CBDDM) strategy was implemented in 115 rural districts to improve the demand for and utilization of maternal and newborn health services. Using the CBDDM strategy, Health Extension Workers (HEWs) fostered the WDA and community leaders to inform, lead, own, plan, and monitor the maternal and newborn health interventions in their kebeles (communities). This paper examines the effectiveness of the CBDDM strategy. METHODS: Using data from cross-sectional surveys in 2010-11 and 2014-15 from 177 kebeles, we estimated self-reported maternal and newborn care practices from women with children aged 0 to 11 months (2124 at baseline and 2113 at follow-up), and a CBDDM implementation strength score in each kebele. Using kebele-level random-effects models, we assessed dose-response relationships between changes over time in implementation strength score and changes in maternal and newborn care practices between the two surveys. RESULTS: Kebeles with relatively high increases in CBDDM implementation strength score had larger improvements in the coverage of neonatal tetanus-protected childbirths, institutional deliveries, clean cord care for newborns, thermal care for newborns, and immediate initiation of breastfeeding. However, there was no evidence of any effect of the intervention on postnatal care within 2 days of childbirth. CONCLUSIONS: This study shows the extent to which an information system for community health volunteers with low literacy was implemented at scale, and evidence of effectiveness at scale in improving maternal and newborn health care behaviors and practices.