by Jenny Dyer, PhD

Over the last ten years, Ethiopia has implemented their Health Extension Worker (HEW) program building Health Posts with HEWs throughout the country. To date, there are some 38,000 HEWs; two at every post. This has amazing reach to communities whose individuals might otherwise have to walk for miles and miles just to have basic services for a sick child, contraception, or antenatal care. This being said, the Health Post does have limitations. The HEW cannot provide a high level of skilled care. For instance, women in Tigray are highly encouraged to take a “mobile ambulance” (i.e. stretcher) to the Health Center where they can have access to skilled health workers that are better prepared to manage complications during birth.

We visited Agulae Health Center in Tigray which won the award for the best Health Center in the country a couple of years ago. The sign outside reads “Healthy Mom, Happy Child.” The Center focuses on maternal and child health , ART treatment, TB treatment, family planning, and youth friendly services, providing a holistic approach for development of identity for teens in the area. Ethiopia is serious about improving maternal health, or conversely, reducing maternal mortality. And, one step to do this is by encouraging moms to have their babies in the health center, not at home.

Inside, patients waited for services including anti-retroviral treatment, immunizations, contraception, antenatal care, and pediatric care. The Health Center Director, Tirete Zeleke, shared with us the progress particularly in delivery services over the last five years. See the chart below. Note that Ethiopia’s calendar is eight years behind ours, so it is 2006 currently. In 2001 (Ethiopian calendar – so 2009), they record that only eight percent of mothers were coming to Agulae to have their newborns. But by 2005 (2013), they note 95 percent were choosing to come to the Center to take advantage of the services and resources for a safer delivery. This is an unbelievable change.

There has been much resistance from Ethiopian women to give birth outside her home. First, the “stretcher” that some communities in Tigray have developed to  carry the pregnant women from their community to the Center, or at least to a paved road to get transportation, has been stigmatized. It was said if you left on the stretcher, you never would return. To destigmatize the stretcher, they now call it a “traditional ambulance.” Secondly, there are rituals to be performed immediately after birth to drive away the evil spirits that might take your life or the life of your newborn. This involves a coffee ceremony and the partaking of porridge. Family and friends in the community join in these rituals, partaking together. The Center has recognized this void for the community, and it has created a space for performing the coffee ritual.

Also, it has required all farmers in the region to donate 1 kilo of teff (an ancient grain) from their harvest to the Center to make the porridge. This attention to community beliefs and ritual has helped break down the cultural barriers that were impeding the women to leave her home during labor.

Lastly, as a final incentive, they have started to create beautiful, laminated birth certificates after one year of postnatal care and infant care. These special documents serve as birth registries and include a photo of the child and all the necessary health care information. Birth registration is so important for establishing name, nationality, and providing the dignity of identity for citizens.

Finally, they have pursued religious leaders to join them in encouraging couples to seek out both family planning options as well as to encourage women to deliver in the Health Centers. The synergy of religious, social, cultural, and governmental forces working together in Tigray has made Agulae Health Center a model for progress in Ethiopia, particularly for maternal health.

Jenny Dyer, PhD

The Center for Strategic and International Studies (CSIS) has pulled together a congressional delegation trip to Ethopia, and they invited me to join them. In leading HTHH’s Faith-Based Coalition for Healthy Mothers and Children Worldwide, I was invited to meet the faith leaders here to learn their stories and the position on the progress of healthy timing and spacing of pregnancies here in Ethiopia.

Ethiopia has achieved the reduction of 2/3 of child mortality for 2015. However, they lag behind, as do many other countries, in addressing maternal mortality. Here, they have rolled out in the last ten years a robust Health Extension Worker (HEW) program of over 35,000 HEWs across the nation. The government manages the HEW program, placing 2 HEWs at a health post to which ideally every person can reach for primary health care services. If there is a health issue that requires a higher level of expertise, the patient is referred to a Health Center, a more substantial facility that has more resources and higher level of trained health workers. This HEW program is taking the lead in educating women about contraception so that they can better time and space their pregnancies. If these young women can delay their first pregnancy and space out their births at least 3 years apart, they have a better chance for their own and their children's survival.

Upon arriving, we quickly got ready and drove across town to the Prime Minister’s residence for a private meeting with the First Lady Roman Tesfaye. Ms. Tesfaye knew we were here to learn more about maternal, newborn, and child health and family planning here in Ethiopia, and she clearly had much enthusiasm discussing her country’s progress in these areas. She spoke at length about her passion for women’s health, particularly around family planning. She explained how family planning was the key to gender equality. With contraception prevalence doubling over the last five years from 15% to 29%, young women are emerging as leaders in their communities. Girls are able to stay in school through high school and then even attend one of their new 32 universities, and women are contributing to the rise of the economy.

Ms. Tesfaye noted, “Family planning is liberating our women. Not only can women now contribute to their own lives, but they are contributing to our country as a whole.” 

The goal for 2015 is to provide 66% women access to contraception or education about healthy timing and spacing of pregnancies. Right now, they expect the 2013 statistics to show that 40% of women have access some form of contraception. Their goal is ambitious, but they believe it is within reach.

Ethiopia has a good story to tell, and Ms. Tesfaye tells that story with elegance and quiet excitement. They have success in decreasing AIDS, decreasing poverty, decreasing infant mortality, and they are increasing their economy. They have also set a focus on decreasing maternal mortality; they are optimistic that the indicators will soon reveal success there due to spacing of pregnancies. It is an exciting moment to be here in the midst of this progress.

Jenny Dyer, PhD

Of all the Millennium Development Goals (MDGs), MDG5, or Improving maternal health, is critical for addressing other global health issues like child survival, extreme poverty and hunger. If Mom dies in childbirth or suffers severe complications, the entire family is in jeopardy. Kids may not be able to finish primary education in order to raise siblings. Mom may suffer from poor health and cannot maintain her job. Newborns lack a mother to nurture them in their first years of life.

Every year about 350,000 women die from pregnancy-related complications. 99 percent of these deaths occur in developing regions, and 80 percent of them are preventable.

Maternal mortality has fallen by 50 percent since 1990, but still only half or women in developing regions receive the recommended health care during pregnancy. The goal is to reduce the maternal mortality ratio by 75 percent by next year. We have far to go.

You can help improve maternal health and combat maternal mortality through learning more about these issues, working alongside groups focusing on maternal health such as Every Mother Counts, and advocating for these women. We encourage you to make a phone call or email your Congressional Leader today to let him/her know that you care about maternal/child health and you want them to fully fund programs which would improve the lives of mothers around the world. 

Resources:

UN: Millennium Development Goals 

Action for Global Health  

The Bill & Melinda Gates Foundation

Bethesda O'Connell, East Tennessee State University

I spent my first night in Guatemala City with Christian Aponte, director of CAFNIMA, my host organization. He helped me review the report I have been working on of the household survey data. We have been fine tuning it to be the most helpful to the organization and people. From there, I took a five-hour bus ride to Cobán and a two-hour truck ride to the Ulpán Valley. 

The major project I have been working on since my arrival is a malnutrition study. We are using the WHO program Anthro to determine which children are chronically and acutely malnourished and require intervention. This determination is based on the height, weight, and age of each child. So far, I have identified fourteen children who were moderately to severely acutely malnourished at the last visit. We will be visiting as many of these children as possible to remeasure them and provide nutritional supplements as well as education to the family on their care. The supplements given with the supervision of a physician based on the United Nations recommendations for in-home recuperation of malnourished children. These interventions have been shown to work—an additional eighteen children were previously acutely malnourished and improved in subsequent measurements following intervention.

The first child we visited as a part of this study had not been previously seen, but a CAFNIMA employee, Ricardo, had been told about him. At our first visit to the home, it appeared that no one was home. We heard noise behind the house and found a six year old boy chained to a post. It was immediately apparent that this was a case of abuse rather than simply lack of food in the home. Because this organization works with the community, this situation needed to be handled delicately. We returned to the home when the adults were present including a mother, aunt, and grandfather. The other four children in the home appeared healthy. We got permission to weigh and measure each child with the intention of focusing on the six-year-old’s situation. After discussion, we found out that this one child was mistreated because of a superstitious belief of the Maya that if the mother experiences trauma during pregnancy, the child is cursed. This belief was further encouraged when he was born early at four pounds. He is currently only 21.8 lbs. We provided the family with supplemental food and vitamins and watched the child eat as fast as he could. Ricardo was communicating with the community authorities to see what could been done to change the situation from an authority standpoint.

The following day, we returned to the home with clothing for all of the children and more food. We gave the boy food again while we were there, and he vomited immediately. We then found out that he had been vomiting and had diarrhea with the food provided the previous day. He also had a cough. We told the family the protocol we were using and the organization physician both advised that with such complications the child be taken to a hospital. They agreed to allow us to take the mother, the sick boy, and a younger sibling who was still breastfeeding to the hospital. It was a long night of trying to get help because it took about three hours to get to the first clinic (with several stops when he would vomit or have diarrhea again) and then we had to take him to another facility. There was a long delay before he was actually registered and began receiving care. We stayed the night in the city to get a few hours of sleep and returned to the hospital the next morning to check on him. They would not allow the younger sibling to stay in the hospital, so we took the mother and baby back to the community and convinced her to leave the baby with the aunt and return to the hospital to stay with the sick boy. All of this was in an effort to reconnect her to her child and learn to care for him again. Additionally, an organization employee filed an official abuse report to the government. The church the family attends has also been involved, and we hope that there will be encouragement from them as well for the family to change their treatment of him as “special.” For now, the child is receiving care and food and the proper actions have been taken to get him legal help as well as to encouraging the family to change their views of him.

All this happened in my first three days in the community. It has been a rude introduction to the needs of the people and the complexity of cultural situations. We have fourteen more children to find and follow up with. I am also providing the organization with further data on all of the children involved in the study. Chronic malnutrition is rampant, with 63% of those measured fitting guidelines for moderate to severe stunting. I pray that we are able to make a difference for these children and families.

Tomorrow my hosts and I will attend a community meeting to promote upcoming dental health fairs.