The authors have declared that no competing interests exist.
Conceived and designed the experiments: AMK. Performed the experiments: KA HA NG AA LT WB. Analyzed the data: AMK JS. Contributed reagents/materials/analysis tools: NG AA LT. Wrote the paper: AMK KA JS WB.
Improving newborn survival is essential if Ethiopia is to achieve Millennium Development Goal 4. The national Health Extension Program (HEP) includes community-based newborn survival interventions. We report the effect of these interventions on changes in maternal and newborn health care practices between 2008 and 2010 in 101 districts, comprising 11.6 million people, or 16% of Ethiopia’s population.
Using data from cross-sectional surveys in December 2008 and December 2010 from a representative sample of 117 communities (
Between 2008 and 2010, median
The results of our analysis suggest that Ethiopia’s HEP platform has improved maternal and newborn health care practices at scale. However, implementation research will be required to address the maternal and newborn care practices that were not influenced by the HEP outreach activities.
Ethiopia is committed to reducing the under-five mortality rate to 68 deaths per 1,000 live births by 2015 in order to achieve Millennium Development Goal four
Simple community-based strategies to improve antenatal, childbirth, and newborn health care practices have been shown to reduce neonatal deaths
The HEP was launched in 2003 and aims to provide universal access to primary health care services
Child survival strategies implemented under the HEP included immunization, vitamin A distribution, oral rehydration therapy, distribution of bed nets, anti-malarial, deworming, and child health and nutrition education. Evidence-based essential newborn care including promotion of clean childbirth practices, clean umbilical cord care, thermal care, extra care for low birth weight babies, and early and exclusive breastfeeding
To the best of our knowledge, previous published evaluations of HEP have been cross sectional studies and have not included community-based essential newborn care
Using a plausibility design based on before-and-after surveys, we explored a dose-response relationship between the changes in program intensity measures in 117
The HEWs, young local women with high school education, were recruited by
Administrative Area | Facility, planned service and staffing |
Provides: Comprehensive emergency obstetric and newborn care and other referral services | |
Staffing: Medical Officers, Health Officers and Nurses | |
Sub- |
|
Provides: Curative services, administrative and technical support for all services provided by health posts, and basic emergency obstetric and newborn care | |
One health centre from each |
|
Rural areas: source for primary health care for MNCH | |
Staffing: Two health extension workers (HEWs) | |
Requirements: female, over 18 years, 10th grade education, serve communities in which they reside, one year training | |
Provide: Prevention services including bed nets, sanitation, breastfeeding, safe and clean delivery, basic ANC and PNC, immunization of children and mothers, family planning and management of childhood illnesses (malaria, diarrhea, pneumonia case management) | |
Seventy-five percent of their time conducts outreach activities including household visits, organize communities, train ‘model families’, and community health promoters provide | |
Support Health Extension Workers | |
Provide: health education to 25 to 30 households | |
Replace Community Health Promoters | |
Provide: health education to five households |
α The average population size of the administrative area is given in parenthesis.
β Number of facilities in the country are given in parenthesis.
From December 2008, the L10K project supported the HEP through 12 local partner organizations. In 101
3.1) Encourage pregnant women to make at least four ANC facility visits and at least one visit to a health centre for review by a nurse or a health officer, and for testing urine for albumin; |
3.2) Biomedical interventions: two doses or one booster of tetanus toxoid injection; iron supplementation; screening for hypertension; |
3.3) Advice on nutrition during pregnancy, birth preparedness, child nutrition, immunization, and essential newborn care; |
3.4) Provision of malaria prophylaxis and promotion of bed nets (malarious areas only). |
4.1) Identify and arrange for a birth attendant; |
4.2) Plan for a specific birth place; |
4.3) Prepare clean and appropriate materials for birth at home; |
4.4 Identify a health facility for birth and emergencies; |
4.5) Financial planning for childbirth and for obstetric emergencies; |
4.6) Identify transport for obstetric emergencies and for birth; |
4.7) Identify a suitable blood donor. |
5.1) Identify someone other than the birth attendant to take care of the newborn immediately after birth; |
5.2) Encourage thermal care, cord care and immediate and exclusive breastfeeding; |
5.3) Monitor the newborn for danger signs that need referral care. |
6.1) Reinforce essential newborn care messages and practices, and ensure clean delivery; |
6.2) Identify danger signs for referral of mother and newborn, using a clinical algorithm; |
6.3) Promote care seeking for newborn and maternal danger signs; |
6.4) Provide counseling on breastfeeding and immunization. |
7.1) Reinforce essential newborn care messages; |
7.2) Provide breastfeeding counseling; |
7.3) Check for newborn and postpartum illnesses, and refer if necessary, using a clinical algorithm. |
The CHPs used a Family Health Card (FHC), a booklet with pictorial messages, to promote focused antenatal care; birth preparedness measures; clean and safe childbirth; recognition of danger signs needing referral in pregnancy, childbirth, and the postnatal period; essential newborn care; infant and childhood nutrition, immunization, and danger signs of childhood illnesses; and household hygiene and sanitation measures (the FHC can be accessed from
Two-stage stratified cluster sampling was done to obtain family planning information from women aged 15 to 49 years; maternal, newborn, and infant health and nutrition information from women with children 0 to 11 months; and child immunization and childhood illness information from women with children 12 to 23 months. The survey instruments for the three target groups were adapted from Demographic and Health Survey
At the first stage,
The interviewers and supervisors were health professionals from regional health bureaus, who received five days of training, including a day of field practice. They did not interview in the areas under their supervision. Survey supervisors and regional coordinators were trained to monitor and supervise the work and ensure data quality. Each survey, including the training period, took about a month. Data was entered twice and differences resolved with reference to the original forms.
The HEP intensity was estimated through household members’ reported exposure to the program. To avoid individual-level selection bias, caused for example by, health-conscious individuals choosing to participate in the program, intervention bias caused by providers targeting individuals based on health behavior, and recall bias caused by differential recall of exposure based on health behavior, we used different respondent groups for measuring program exposure and outcomes. The HEP intensity measures were
The
A
The essential maternal and newborn care practices that were expected to contribute towards improved neonatal survival
1.1) Receiving any antenatal care (ANC) service at a health facility; | ||
1.2) Iron supplementation at least once during ANC; | ||
1.3) At least two tetanus toxoid injections during ANC; | ||
1.4) The number of preparedness measures taken, including financial, transport, food, birth attendants, identifying a health facility, preparing clean materials for delivery, identifying a blood donor. | ||
2.1) Institutional delivery at a health centre or hospital; | ||
2.2) Delivery assisted by skilled birth attendant (doctor, nurse, or a midwife); | ||
2.3) Receiving post-natal care at home by a Health Extension Worker (HEW); | ||
2.4) Receiving post-natal care by a HEW within seven days of childbirth. | ||
3.1) Newborn is dried and wrapped immediately following childbirth (or within an hour); | ||
3.2) Bathing the newborn is delayed by more than six hours; | ||
3.3) Skin-to-skin contact with the newborn always–as opposed to often, few times, or never maintained; | ||
3.4) Took thermal care: dried and wrapped baby, delayed bathing, and maintained skin-to-skin contact. | ||
4.1) Cut umbilical cord with sterile instrument among deliveries without skilled attendance; | ||
4.2) Tying the umbilical cord with sterile thread among deliveries without skilled attendance; | ||
4.3) Apply nothing on the cut stump of the umbilical cord; | ||
4.4) Clean cord care: if the umbilical cord was cleanly cut and tied, and nothing was applied to the stump, among deliveries without a skilled attendant. | ||
5.1) Newborn is given colostrum (first milk); | ||
5.2) Newborn is put to breast immediately (within one hour) of birth; | ||
5.3) Exclusively breast feeding the baby during the last 24 hours (among women with a child aged less than one month). | ||
Excessive vaginal bleeding | Excessive vaginal bleeding | Vomiting |
Foul-smelling discharge | Foul-smelling discharge | Fever |
High fever | High fever | Poor sucking or feeding |
Baby’s hand or feet come first, | Severe abdominal pain | Difficulty in breathing, |
Baby in abnormal position | Convulsions | Baby feels cold |
Prolonged labor >12 hours | Baby too small/early birth | |
Retained placenta | Redness/discharge on cord | |
Ruptured uterus | Red swollen eye/discharge, | |
Prolapsed cord | Yellow palm/sole/eye, | |
Cord around neck, | Lethargy | |
Convulsions | Unconscious |
α Cronbach’s coefficients of the three knowledge scores were low (<0•37). The knowledge scores reflected the number of correct knowledge items spontaneously recalled by women.
The
The average change in the prevalence of a maternal and newborn care practice ‘
The program effect, i.e., ‘
In such cases, the multi-level analysis is appropriate which allows assessing the associations between
A maternal and newborn care practice ‘
Respondent characteristics | Baseline | Follow-up | p-value | |||
% | N | % | N | |||
100•0 | 1,404 | 100•0 | 1,404 | |||
15–19 | 8·7 | 122 | 8·3 | 116 | 0•114 | |
20–34 | 76·4 | 1,073 | 73·7 | 1,035 | ||
35–49 | 14·3 | 201 | 17·3 | 243 | ||
Missing | 0·6 | 8 | 0·7 | 10 | ||
Age of last child (months) | <1 | 5·3 | 74 | 4·6 | 64 | 0•003 |
1–5 | 40·1 | 563 | 47·3 | 664 | ||
6+ | 54·2 | 761 | 47·7 | 670 | ||
Missing | 0·4 | 6 | 0·4 | 6 | ||
Marital status | Unmarried/single | 5·0 | 70 | 5·3 | 75 | 0•699 |
Married/living together | 94·4 | 1,325 | 93·8 | 1,317 | ||
Missing | 0·6 | 9 | 0·9 | 12 | ||
Education | None | 75·5 | 1,060 | 75·4 | 1,059 | 0•194 |
Primary | 14·0 | 196 | 13·5 | 190 | ||
Secondary or higher | 7·3 | 102 | 9·3 | 131 | ||
Missing | 3·3 | 46 | 1·7 | 24 | ||
Number of children | 1 | 19·0 | 266 | 18·9 | 265 | 0•424 |
2 | 18·7 | 263 | 16·3 | 229 | ||
3 | 16·5 | 232 | 17·0 | 239 | ||
4+ | 45·2 | 634 | 47·2 | 663 | ||
Missing | 0·6 | 9 | 0·6 | 8 | ||
Religion | Orthodox | 59·1 | 830 | 58·3 | 819 | 0•347 |
Protestant | 13·3 | 186 | 15·2 | 213 | ||
Muslim | 25·6 | 359 | 24·6 | 345 | ||
Traditional/other | 1·4 | 19 | 1·0 | 14 | ||
Missing | 0·7 | 10 | 0·9 | 13 | ||
Distance to drinking water source | In compound | 3·4 | 47 | 2·1 | 30 | <0•001 |
<30 minutes | 74·8 | 1,050 | 85·7 | 1,203 | ||
30+ minutes | 21·0 | 295 | 11·8 | 165 | ||
Missing | 0·9 | 12 | 0·4 | 6 | ||
Distance to any health facility | <30 min. | 53·1 | 745 | 62·0 | 871 | <0•001 |
30 min–<1 hr | 24·1 | 338 | 28·3 | 397 | ||
1-<2 hrs | 14·8 | 208 | 7·5 | 105 | ||
2+ hrs | 7·5 | 105 | 1·8 | 25 | ||
Missing | 0·6 | 8 | 0·4 | 6 | ||
Frequency of listening to radio | Almost every day | 20·3 | 285 | 21·7 | 304 | 0•137 |
At least once a week | 13·8 | 194 | 13·0 | 183 | ||
Less than once a week | 4·6 | 65 | 3·0 | 42 | ||
Not at all | 60·5 | 849 | 61·7 | 866 | ||
Missing | 0·8 | 11 | 0·6 | 9 | ||
Wealth quintile β | Poorest | 20·7 | 291 | 20·1 | 282 | 0•274 |
Medium poor | 20·7 | 290 | 21·2 | 298 | ||
Middle | 21·5 | 302 | 20·3 | 285 | ||
Medium rich | 22·7 | 318 | 20·8 | 292 | ||
Richest | 13·4 | 188 | 16·6 | 233 | ||
Missing | 1·1 | 15 | 1·0 | 14 | ||
Distance to basic emergency | 1 | 21·4 | 300 | 17·1 | 240 | 0•184 |
obstetric care from |
2 | 20·5 | 288 | 17·1 | 240 | |
3 | 10·3 | 144 | 20·5 | 288 | ||
4+ | 42·7 | 600 | 42·7 | 600 | ||
Missing | 5·1 | 72 | 2·6 | 36 |
β The wealth index score was constructed for each household with the principal component analysis of the household possessions (electricity, watch, radio, television, mobile phone, telephone, refrigerator, table, chair, bed, electric stove, and kerosene lamp), and household characteristics (type of latrine and water source). The households were ranked according to the wealth score and then divided into five quintiles indicating poor, medium poor, medium, medium rich and rich households
The likelihood ratio global statistics of the logit models and the global F-statistics of the linear regression models were used to assess the goodness-of-fit of the models.
The fixed-effect model applied to panel surveys with two points in time (such as our study design) is analogous to the first difference model described by
Lastly, a counterfactual analysis was done to quantify the program effects on maternal and newborn care practices. First, we predicted the prevalence of a maternal and newborn care practice by using the multi-level model described by
The 117
The distribution of women’s age, marital status, education, parity, religion, frequency of radio listenership, household wealth quintile, and the distance to basic emergency obstetric care from the
The
Program intensity measures | Baseline | Follow-up | Change | (95% CI) | |
Household visits by a HEW | Mean | 37·0 | 49·2 | 12·3 | (6·2–18·3 ) |
Median | 40·0 | 50·0 | 10·0 | (1·4–18·6) | |
Household visits by a CHP | Mean | 20·6 | 33·3 | 12·6 | (8·5–16·8) |
Median | 13·0 | 33·3 | 20·3 | (11·7–28·9) | |
FHC possession | Mean | 8·6 | 33·7 | 25·1 | (20·7–29·5) |
Median | 0·0 | 30·0 | 30·0 | (23·2–36·8) | |
‘Model family’ household | Mean | 11·0 | 27·6 | 16·6 | (12·4–20·8) |
Median | 6·7 | 22·7 | 16·1 | (9·3–22·8) | |
Mean | 2·2 | 4·0 | 1·9 | (1·5–2·2) | |
Median | 2·0 | 4·1 | 2·1 | (1·6–2·6) |
With the exception of tetanus toxoid injection during pregnancy and cutting the umbilical cord with a sterile instrument, we found evidence of improvement in all maternal and newborn care practices (
Maternal & newborn care outcomes | Baseline | Follow-up | Change | |||
Prenatal care and birth preparedness | Estimate | Obs. | Estimate | Obs. | Estimate | (95% CI) |
% received antenatal care (ANC) | 57·6 | 1,401 | 70·2 | 1,403 | 12·6 | (9·5–15·8) |
% given iron supplement | 13·7 | 1,401 | 31·7 | 1,403 | 18·0 | (15·3–20·8) |
% received at least two TT injection | 41·3 | 1,389 | 43·6 | 1,392 | 2·4 | (–0·1–5·9) |
% taken any birth preparedness measures | 69·4 | 1,400 | 75·1 | 1,395 | 5·6 | (2·4–8·9) |
% had institutional delivery | 6·2 | 1,398 | 10·6 | 1,398 | 4·4 | (2·6–6·3) |
% of deliveries assisted by skilled birth attendance | 8·2 | 1,404 | 11·3 | 1,404 | 3·1 | (1·0–5·1) |
% received PNC | 4·6 | 1,404 | 15·3 | 1,404 | 10·8 | (8·6–12·9) |
% received PNC in seven days | 3·1 | 1,404 | 9·9 | 1,404 | 6·8 | (5·0–8·6) |
Thermal care | ||||||
% dried and wrapped baby immediately following childbirth | 69·4 | 1,404 | 75·0 | 1,404 | 5·6 | (2·4–8·8) |
% delayed bathing the newborn by more than six hours | 25·3 | 1,365 | 38·4 | 1,373 | 13·1 | (10·0–16·3) |
% always maintained skin-to-skin contact with newborn | 70·8 | 1,403 | 76·9 | 1,400 | 6·1 | (3·2–9·0) |
% took thermal care | 10·5 | 1,364 | 24·5 | 1,372 | 14·1 | (11·4–16·8) |
Clean cord care | ||||||
% of home deliveries cut umbilical cord with sterile instrument | 95·9 | 1,233 | 96·0 | 1,163 | 0·2 | (–1·3–1·8) |
% of home deliveries tied umbilical cord with sterile thread | 57·6 | 1,233 | 62·4 | 1,163 | 4·8 | (0·9–8·8) |
% applied nothing on umbilical cord cut | 67·7 | 1,348 | 74·0 | 1,338 | 4·3 | (1·1–7·3) |
% took clean cord care | 36·3 | 1,190 | 45·6 | 1,109 | 9·3 | (5·3–13·3) |
Breastfeeding practices | ||||||
% gave baby colostrums | 46·2 | 1,404 | 53·3 | 1,404 | 7·1 | (3·5–10·6) |
% put baby to breast immediately after birth | 46·0 | 1,404 | 54·2 | 1,404 | 8·2 | (4·7–11·6) |
% exclusively breastfeeding their neonates | 82·4 | 74 | 95·3 | 64 | 12·9 | (2·2–23·5) |
Maternal danger sign during childbirth score (0–11) | 1·90 | 1,396 | 2·20 | 1,400 | 0·30 | (0·22–0·38) |
Maternal danger sign during postnatal period score (0–5) | 1·39 | 1,388 | 1·70 | 1,397 | 0·31 | (0·25–0·38) |
Neonatal danger sign score (0–11) | 1·87 | 1,400 | 2·03 | 1,397 | 0·26 | (0·10–0·24) |
An increase in
Kebele-level scatter plots with fitted regression lines between changes in maternal and newborn health care practices/knowledge and changes in
Estimated effects of
Maternal & newborn care outcomes | HH visits by HEW | HH visits by CHP | FHC possession | Model family HH | |||||||||||
OR | (95% CI) | p-value | OR | (95% CI) | p-value | OR | (95% CI) | p-value | OR | (95% CI) | p-value | OR | (95% CI) | p-value | |
Received antenatal care (ANC) | 1·06 | (1·00–1·12) | 0•047 | 1·11 | (1·02–1·20) | 0•011 | 1·05 | (0·97–1·13) | 0•220 | 1·08 | (1·00–1·17) | 0•054 | 1·13 | (1·03–1·23) | 0•008 |
Given iron supplement | 1·01 | (0·94–1·09) | 0•719 | 1·13 | (1·03–1·24) | 0•008 | 1·16 | (1·07–1·27) | 0•003 | 1·04 | (0·94–1·14) | 0•474 | 1·14 | (1·02–1·26) | 0•018 |
Received at least two TT injection | 1·06 | (1·01–1·12) | 0•020 | 1·11 | (1·03–1·20) | 0•004 | 1·04 | (0·97–1·11) | 0•293 | 0·98 | (0·91–1·05) | 0•508 | 1·09 | (1·00–1·18) | 0•043 |
Taken any birth preparedness measures | 1·16 | (1·10–1·23) | <0•001 | 1·17 | (1·07–1·28) | <0•001 | 1·16 | (1·07–1·26) | 0•001 | 1·20 | (1·10–1·30) | <0•001 | 1·31 | (1·19–1·44) | <0•001 |
Had institutional delivery | 0·92 | (0·83–1·01) | 0•092 | 0·97 | (0·83–1·13) | 0•718 | 0·98 | (0·86–1·12) | 0•782 | 0·90 | (0·77–1·06) | 0•203 | 0·89 | (0·75–1·05) | 0•164 |
Skilled birth attendance | 0·94 | (0·86–1·03) | 0•194 | 0·94 | (0·82–1·08) | 0•380 | 0·95 | (0·84–1·07) | 0•392 | 0·87 | (0·75–1·00) | 0•054 | 0·87 | (0·75–1·02) | 0•082 |
Received any PNC | 1·35 | (1·21–1·51) | <0•001 | 1·39 | (1·20–1·61) | <0•001 | 1·22 | (1·07–1·40) | 0•003 | 1·20 | (1·01–1·42) | 0•036 | 1·60 | (1·34–1·91) | <0•001 |
Received PNC within seven days | 1·25 | (1·10–1·42) | <0•001 | 1·36 | (1·14–1·61) | 0•001 | 1·24 | (1·06–1·45) | 0•007 | 1·20 | (0·98–1·45) | 0•071 | 1·53 | (1·24–1·88) | <0•001 |
Dried and wrapped baby immediately following birth | 1·00 | (0·95–1·06) | 0•865 | 0·98 | (0·91–1·06) | 0•675 | 0·94 | (0·87–1·02) | 0•119 | 0·87 | (0·80–0·93) | <0•001 | 0·93 | (0·85–1·01) | 0•085 |
Delayed bathing the newborn by more than six hrs. | 0·99 | (0·93–1·05) | 0•749 | 1·00 | (0·91–1·08) | 0•915 | 1·10 | (1·01–1·19) | 0•024 | 0·90 | (0·82–0·98) | 0•011 | 0·99 | (0·90–1·09) | 0•835 |
Always maintained skin-to-skin contact with newborn | 1·10 | (1·03–1·18) | 0•004 | 1·00 | (0·91–1·09) | 0•940 | 1·12 | (1·03–1·23) | 0•010 | 0·83 | (0·77–0·90) | <0•001 | 1·02 | (0·93–1·13) | 0•646 |
Took thermal care of baby | 1·07 | (1·00–1·16) | 0•066 | 1·02 | (0·92–1·13) | 0•691 | 1·13 | (1·02–1·24) | 0•021 | 0·76 | (0·69–0·85) | <0•001 | 1·00 | (0·89–1·12) | 0•983 |
Tied umbilical cord with sterile thread | 1·09 | (1·02–1·16) | 0•013 | 1·21 | (1·10–1·34) | <0•001 | 1·04 | (0·95–1·14) | 0•407 | 1·04 | (0·95–1·14) | 0•363 | 1·15 | (1·04–1·27) | 0•006 |
Applied nothing on the cut umbilical cord | 1·05 | (0·99–1·11) | 0•115 | 0·99 | (0·91–1·08) | 0•824 | 1·02 | (0·95–1·10) | 0•606 | 1·03 | (0·94–1·11) | 0•552 | 1·05 | (0·96–1·15) | 0•320 |
Took clean cord care | 1·04 | (0·98–1·10) | 0•192 | 1·10 | (1·01–1·20) | 0•037 | 1·00 | (0·92–1·08) | 0•978 | 0·99 | (0·91–1·08) | 0•901 | 1·06 | (0·96–1·16) | 0•245 |
Gave baby colostrums | 1·00 | (0·96–1·06) | 0•777 | 0·94 | (0·88–1·02) | 0•122 | 1·01 | (0·95–1·09) | 0•673 | 1·01 | (0·94–1·08) | 0•756 | 1·00 | (0·92–1·08) | 0•915 |
Putting baby to breast immediately after birth | 1·04 | (0·99–1·10) | 0•128 | 1·00 | (0·93–1·08) | 0•974 | 1·12 | (1·05–1·21) | 0•001 | 1·08 | (1·00–1·16) | 0•048 | 1·10 | (1·01–1·20) | 0•017 |
Coef. | Coef. | Coef. | Coef. | Coef. | |||||||||||
0·02 | (−0·01,0·04) | 0•143 | 0·05 | (0·02, 0·09) | 0•004 | 0·04 | (0·00, 0·07) | 0•044 | 0·05 | (0·01, 0·09) | 0•007 | 0·06 | (0·02, 0·10) | 0•002 | |
0·01 | (−0·01,0·03) | 0•590 | 0·05 | (0·02, 0·08) | 0•001 | 0·03 | (0·00,0·06) | 0•032 | 0·01 | (−0·02,0·04) | 0•512 | 0·04 | (0·00,0·07) | 0•031 | |
0·00 | (−0·02,0·02) | 0•858 | 0·04 | (0·01, 0·07) | 0•009 | 0·04 | (0·01, 0·07) | 0•006 | 0·03 | (−0·01,0·06) | 0•114 | 0·04 | (0·00,0·07) | 0•034 |
For a ten percentage point increase in the
Although we found no association between
Contrary to expectation, we found some evidence that
We found no evidence that the
The counterfactual analysis indicated that the program effects, i.e., the effects of
Maternal and newborn care outcomes | HH visits by HEW | HH visits by CHP | FHC possession | Model family HH | |
Received antenatal care (ANC) | 5.2 | 6.5 | 8.9 | ||
Given iron supplement | 5.9 | 7.7 | 7.4 | ||
Received at least two TT injection | 6.3 | 7.6 | 7.0 | ||
Taken any birth preparedness measures | 14.0 | 9.7 | 9.2 | 8.9 | 20.1 |
Had institutional delivery | |||||
Skilled birth attendance | |||||
Received any PNC by HEW | 8.5 | 7.7 | 5.8 | 4.4 | 11.2 |
Received PNC by HEW within 7 days | 5.4 | 5.4 | 4.7 | 7.8 | |
Dried and wrapped baby | −7.3 | ||||
Delayed bathing the newborn | 5.5 | −5.4 | |||
Always maintained skin-to-skin contact | 8.9 | 7.0 | −8.5 | ||
Took thermal care | 5.5 | −10.6 | |||
Tied umbilical cord with sterile thread | 7.2 | 11.8 | 10.1 | ||
Applied nothing on the cut umbilical cord | |||||
Took clean cord care | 6.3 | ||||
Gave baby colostrums | |||||
Putting baby to breast immediately after childbirth | 8.5 | 4.3 | 8.4 | ||
0.18 | 0.12 | 0.14 | 0.25 | ||
0.17 | 0.10 | 0.14 | |||
0.14 | 0.14 | 0.15 |
Only the statistically significant effects in
All the program effects are attributable fractions (percentage-points); while the program effects on knowledge are attributable means.
Our study is unusual in reporting effectiveness of community-based newborn survival interventions integrated within the HEP at scale, in a population of 11.6 million people. We found strong evidence of a dose-response relationship between the HEP and better care practices, which indicate that the program is an effective platform for improving community-based newborn care practices at scale. Among the four strategic elements of outreach making up our
We previously reported a cross-sectional association between maternal care practices and HEP outreach intensity measures observed in December 2008, before strengthening the essential newborn care practices package evaluated here
Prior to 2011 the ‘model family’ training module did not include essential newborn care practices. If a ‘model family’ household had cultural practices that were undesirable for newborn health, then by virtue of being a model in the neighborhood they would be promoting this undesirable practice. The apparent undesirable influence of ‘model families’ on thermal care of the newborn should be mitigated by the introduction of the updated ‘model family’ training module that includes essential newborn care practices
There are several limitations to this study. First, the findings from the
Nevertheless, the validity of the scale measuring program intensity, i.e., the
Although there was improvement over a two year period in the proportion of deliveries done in health facilities and attended by skilled health professionals; drying and wrapping the newborn immediately following childbirth; applying nothing on the cut umbilical cord; and giving colostrum, we found no evidence that the HEP outreach strategies were responsible for these changes. The improvements in these indicators could be due to other aspects of the HEP. For example, improvement in skilled deliveries could be explained by improved availability and accessibility to the service. Providing health education to mothers on newborn health care practices is generally done through antenatal visits; in which case, the intensity of the HEWs outreach activities would not be associated with them. However, implementation research will be required to identify why HEP outreach activities failed to affect some of the maternal and newborn care practices, and to develop and test practical solutions for addressing them.
We estimated the impact on neonatal mortality of the improvements in maternal and newborn care practices using the Lives Saved Tool (
Since late 2011 integrated refresher training for HEWs has been implemented throughout the country, including the essential newborn care practices described here as well as community case management of childhood illnesses
Better maternal and newborn care practices are necessary for improving newborn survival at scale, and they may also pave the way for further interventions. Applying chlorhexidine to the umbilical cord stump to prevent sepsis
In conclusion, this study suggests that the integration of community-based essential newborn care package within the HEP, through integrated refresher training of the HEWs, would have a measureable impact on newborn survival. Among the strategic elements of the outreach activities the use of the FHC has been the most effective; however, not all rural households have a FHC, and the HEP should address this gap. Utilizing a network of CHPs to extend the reach of the HEWs was also found as an effective strategy. The ‘health development army’ is thus likely to be a promising strategy to mobilize communities to improve maternal and newborn health. Lastly, a refresher training of the ‘model family’ should be initiated so that they are well aware of the essential newborn care practices.
The HEP outreach activities had little effect on institutional and skilled deliveries for which higher level service providers, supporting technical staff, infrastructure, equipments, supplies, and including a functional referral system, are required. The Government of Ethiopia is taking appropriate measures to strengthen the health systems to ensure universal access to skilled delivery care. Implementation research can support this, to identify the roles of providers within the primary health care unit to maximize the utilization of services that are being made available.
We thank the health extension workers, community health promoters, and the women in the L10K areas for making this research possible. The supports from the Regional Health Bureaus of Amhara, Oromia, Tigray, and Southern Nations and Nationalities People’s Regions, and the L10K implementing partners, i.e., Amhara Development Association, Bench Maji Development Association, Ethiopian Kale Hiwot Church, Fayyaa Integrated Development Organization, Illu Women and Children Integrated Development Association, Oromia Development Association, Relief Society of Tigray, Sheka Peoples’ Development Association, Siltie Development Association, Southern Region’s Women’s Association, and Women’s Association of Tigray were critical for the data collection. Logistics, supervision, and management supports throughout the study period by the L10K central and regional team members were fundamental for conducting the study. We are thankful to Mary Taylor for her support. The review of the paper by W Brown, S Hodgins and E Allen were very useful for finalizing the manuscript. Comments from S Cousens on an early analysis of the L10K baseline and follow-up survey data were very helpful. A Becker helped us with the illustrations.