1. International SBCC Summit
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

2. Presentation outline Background Study:
The Health Extension Program and L10K interventions
Study:
Methods and analysis
Results
Conclusions
Lessons learned and recommendations

3. Background: Ethiopia
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

4. Ethiopian Healthcare Delivery System
Specialized Hospital
( million People)
General Hospital
(1-1.5 million People)
Primary Hospital: 100, ,000
Rural Health Center: 15, ,000
Rural Health Post: 3,000- 5,000
20-30 HDAs teams
150 1:5 Networks

5. Ethiopian Primary Healthcare System
Health Center
Health
Post 1
Post 2
Post 3
Health Development Teams
(25 HDA teams)/ kebele
Post 4
Post 5

6. 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

7. 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

8. Family Conversation
A family level dialogue at the pregnant woman’s home where her husband, mother in-law, 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

9. Family Conversation Guides

10. 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)

11. 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

12. Prevalence of selected MNCH practices in 115 districts of L10K areas, 2011 and 2015

13. % 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

14. 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
3.8
(-6.9, 14.5)
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
*4.9
(2.2, 7.5)
*Statistically significant effects (p<0.05)

15. Conclusions
Family conversation improved coverage of institutional delivery, PNC with in 48 hours, thermal care and exclusive breastfeeding

16. 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