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

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

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

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 Post 2 Post 3 Health Development Teams (25 HDA teams)/ kebele Post 4 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 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

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

% 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 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)

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