FINAL REPORT ON THE PILOT COMMUNITY MOBILIZATION ... · The purpose of this report is to present the findings of the evaluation of the Pilot Community Mobilization / Education Project

November 26, 2007

FINAL REPORT ON THE PILOT COMMUNITY MOBILIZATION / EDUCATION PROJECT

FOR PROMOTION OF SAFE MOTHERHOOD AND PREVENTION OF OBSTETRIC FISTULA IN ERITREA

Final November 2007

Prepared by Janet Molzan Turan, PhD of the University of California, San Francisco and Stanford University, in collaboration with the Eritrean Ministry of Health and the United Nations Population

Fund (UNFPA)

Final, November 26, 2007

ACKNOWLEDGEMENTS First, we would like to thank the women, health workers, maternal health volunteers (MHVs), and other community members in Kamchewa, Afabet, and Haboro who gave their time and shared their experiences with us during this intervention study. We also acknowledge the hard work of the data collection teams who conducted the survey, focus groups, and one-on-one interviews in the two study areas. The field work for this project, including the final assessment data collection, was supervised by the Health Promotion Unit of the Eritrean Ministry of Health, under the direction of Mekonnen Tesfagiorghis. The data management team responsible for translating, coding, entering, and cleaning the data included Beshir Salih and Mussie Tessema of the HPU and Amanuel Ammanuel Kifle from the HRD Unit. We thank Senait Mesfin for her work translating the final assessment focus group and interview data. We also greatly appreciate the assistance of Fatima Hassan (undergraduate student at Stanford University) in cleaning and tabulating the final assessment survey data in Asmara in July 2007 and in organizing and summarizing the qualitative data from the focus groups and in-depth interviews. We also appreciate helpful feedback throughout the duration of the study from Dr. Berhane Ghebretinsae (Director General of the MOH), Dr. Berhana Haile (Head of the Reproductive Health Unit of the MOH), Dr. Berhane Debru (Head of Clinical Services in the MOH) and Charlotte Gardener, Dirk Jena, and Elsa Mengasteab of the UNFPA Eritrea Office. We acknowledge the financial and logistical support of the Eritrea Office of the United Nations Population Fund (UNFPA) and the Eritrean Ministry of Health (MOH) in carrying out this project.

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TABLE OF CONTENTS Abbreviations 1 Executive Summary 2 Introduction and background 4 The community education / mobilization intervention 5 Evaluation design and methods 11 Findings Summary of baseline findings 15 Summary of mid-intervention findings 15 Final assessment findings Survey 16 Focus groups and qualitative interviews 25 Health facility statistics 28 Discussion 31 Recommendations 33 References 34 Appendices

Appendix 1: Final assessment questionnaire Appendix 2: Moderator’s guides for focus groups with maternal health volunteers Appendix 3: Characteristics of focus group and qualitative interview participants Appendix 4: Monitoring and supervision forms Appendix 5: Tables comparing the intervention and control areas at the time of the

final assessment

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ABBREVIATIONS ANC: Antenatal Care APH: Antepartum Hemorrhage CPD: Cephalo-Pelvic Disproportion DG: Discussion Group ECD: Early Child Development EmOC: Emergency Obstetric Care EPI: Expanded Program on Immunization FGM: Female Genital Mutilation HC: Health Center HF: Health Facility HW: Health Worker HPU: Health Promotion Unit IEC: Information, Education, and Communication IPC: Interpersonal Communication LSS: Life Saving Skills MCH: Maternal and Child Health MHV: Maternal Health Volunteer MOE: Ministry of Education MOH: Ministry of Health NRSZ: Northern Red Sea Zone NUEW: National Union of Eritrean Women NUEY&S: National Union of Eritrean Youth & Students PFDJ: People's Front for Democracy and Justice PHC: Primary Health Care RH: Reproductive Health TBA: Traditional Birth Attendant TTBA: Trained Traditional Birth Attendant UCSF: University of California, San Francisco UNDP: United Nations Development Programme UNFPA: United Nations Population Fund

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EXECUTIVE SUMMARY This report presents the findings of the evaluation of the Pilot Community Mobilization / Education Project for Promotion of Safe Motherhood and Prevention of Obstetric Fistula in Eritrea. The overall aim of this intervention was to promote community knowledge, attitudes, and practices for safe motherhood, and thus contribute to the prevention of obstetric fistula and other maternal and infant complications. The project was conducted in Kamchewa in the Northern Red Sea Zone of Eritrea, and the neighboring district of Haboro in Anseba Zone was selected as a comparison area. The main focus of the intervention was the training of female and male Maternal Health Volunteers (MHVs) to lead a series of participatory sessions with community members on safe motherhood issues. In addition, the intervention included efforts to strengthen local health facilities, including training of health workers in interpersonal communication and infrastructure improvements. Evaluation of the project was conducted using a quasi-experimental study design (nonequivalent group pretest-posttest) in order to evaluate the impact of the community intervention on knowledge, attitudes, and practices related to safe motherhood and prevention/treatment of obstetric fistula. The evaluation design included: 1) baseline data collection in one intervention and one control community, 2) implementation of intervention activities in the intervention community, 3) a mid-intervention process evaluation, and 4) final assessment data collection in intervention and control communities one year after initiation of the intervention. The evidence from the evaluation research indicates that the community education and mobilization strategy used in this pilot project is a very promising one for the promotion of safe motherhood in Eritrea. Alongside urgently needed improvements in transportation, access to emergency obstetric care, and the quality of maternity services, it appears that this type of community effort can make a contribution to improving maternal and infant health in this setting. Particularly impressive are the high activity levels and continued motivation of the Maternal Health Volunteers, the increases in the use of ANC and HF delivery services at the Kamchewa HC, and the significant increases in knowledge and attitudes related to safe motherhood in Kamchewa. Although comparison with the control area indicates that there were general improvements in safe motherhood knowledge in other parts of Eritrea as well during this time period, it appears that the intervention did have larger and significant positive effects on knowledge of pregnancy and birth danger signs as well as birth preparedness in Kamchewa. The evaluation results indicate that behavior change in Kamchewa was greatest in the area of utilization of ANC services, illustrated by more use of any ANC, more total visits during pregnancy, and first visits earlier in pregnancy, as compared to baseline. It appears that there were also significant increases in health facility delivery in Kamchewa, although the evaluation results are not conclusive. The increases in maternity service use reported by women in Kamchewa in the survey are supported by the focus group data and the health facility service statistics. Findings from the survey and focus groups also indicate that the quality of maternity care (based on women’s assessments of the way they were treated by health workers during ANC and delivery) improved during the intervention period in the intervention area, but not in the control area. Overall, despite the challenges in implementing the intervention and limitations in the evaluation methods, the evaluation results indicate that this relatively low-cost community intervention was successful in increasing maternal health knowledge, attitudes, and practices in Kamchewa. It is impressive that this much change could be seen in a relatively short amount of time and it is possible that the effects will be even greater if the Maternal Health Volunteer intervention continues. It seems clear that the MHV intervention should continue to be supported in

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Kamchewa. In addition, similar strategies could be used in other parts of Eritrea, with modifications suggested in the recommendations section of this report.

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INTRODUCTION AND BACKGROUND The purpose of this report is to present the findings of the evaluation of the Pilot Community Mobilization / Education Project for Promotion of Safe Motherhood and Prevention of Obstetric Fistula in Eritrea. The project is a partnership between the Eritrean Ministry of Health and the local community, with support from UNFPA and Stanford University’s Eritrean Women’s Health Project. Rationale for community mobilization and education for promotion of safe motherhood and prevention of obstetric fistula: Increasingly, work done in the field of international development is showing that communities can make deep and lasting contributions to their own health and well-being [1]. It is important to mobilize people to have an active role in the management of community health problems in order to ensure that this management is sustainable. Several benefits can emerge from empowering communities to address health problems. Communities can contribute resources that are not present within the formal healthcare system, and can see to it that information is provided to those individuals who are hardest to reach. In turn, community members can be encouraged to vocalize their needs to government officials, and to speak out against social injustices that are impacting the health of their families [1]. By directly involving community members in health promotion interventions, communities realize their ability to affect change and to serve as advocates for themselves. Undoubtedly, much can be accomplished when citizens work together to meet their own needs. An area of public health in which community mobilization has made a substantial contribution is in the promotion of maternal and child health. A number of successful examples of the effects of community action exist. In Bolivia, 50 poor, isolated communities cut newborn mortality by more than half in three years. Families adopted healthier practices, developed emergency transport and financial systems, and increased women’s involvement in community decision making. This community mobilization approach was later extended to 500 additional communities in Bolivia, and was adapted for use in other countries [1]. In the Nyanza Province of Kenya, with a population of 5 million, a team of community members recently worked together to secure funding from international agencies and Kenyan breweries to build a new operating theatre in the province, secure more delivery tables for health centers, and provide salaries for some of the traditional birth attendants working in the area. These steps were taken as part of the group’s involvement in Columbia University’s Prevention of Maternal Mortality Network [2]. The decline of maternal mortality ratios in countries such as Indonesia and Zimbabwe during the late 1990s was assisted by community-based interventions that helped to reach women in remote parts of these countries [3]. Recent projects in Guatemala [4] and Ghana [5] have shown that community mobilization can be effective in increasing community knowledge and practice for safe motherhood. A cluster randomized controlled trial of a participatory community intervention focused on improving birth outcomes in Nepal [6] found significant reductions in neonatal and maternal mortality in intervention clusters, as compared to control clusters. Although it is essential to upgrade referral facilities and train skilled attendants, these improvements take time and resources and may not be enough to ensure safe motherhood and prevent obstetric fistula [7]. Efforts towards community empowerment can prove to be a cornerstone in the reduction of obstetric fistula in Eritrea and result in an increase in safe motherhood practices.[8] The United Nations Population Fund (UNFPA), as part of the international Obstetric Fistula Working Group, has already identified the importance of involving

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communities in efforts to increase awareness about the role of safe motherhood practices in the prevention of fistula. The overall goal of this pilot intervention was to empowering the community to take an active role in the promotion of safety and well-being amongst delivering mothers. Background on safe motherhood and obstetric fistula efforts in Eritrea: The Eritrean MOH, in partnership with other government agencies and international donors, has an active program for the promotion of safe motherhood, which includes significant efforts to strengthen human and physical resources for the delivery of emergency obstetric care (EmOC). This program includes Life Saving Skills (LSS) training for nurses and associate nurses and over 400 have been trained so far and are working in health facilities all over the country. Community projects have also been established to increase awareness of women’s health and safe motherhood issues in rural areas. These include an advocacy campaign for discouragement of female genital mutilation (FGM), HIV/AIDS prevention activities, and training of community volunteers in different zones of the country. The Eritrean Obstetric Fistula Project, supported by UNFPA, includes 1) training of health care providers on obstetric fistula prevention, repair, and management; 2) use of information, education, and communication (IEC) and community mobilization strategies to promote community awareness and adoption of positive behaviors for maternal health; 3) provision of drugs and medical equipment necessary for repair and treatment of fistula; and 4) the establishment of a dedicated fistula center in an existing hospital. Beginning in 2002, the MOH and UNFPA have coordinated the annual visits of a team of US physicians who perform a number of complex fistula repairs and train Eritrean physicians in the surgical management of obstetric fistula. A total of 8 such trips have been conducted and as a result over 350 women have received fistula repairs. In 2006, a dedicated fistula department was established in Mendefera Hospital in a central location in the country, staffed by an obstetrician/gynaecologist experienced in fistula repair and trained nurses, and a small pre- and post-surgery hostel for fistula patients was established near the hospital in 2007. There are plans to build a more comprehensive hostel for fistula patients on the hospital grounds. The pilot community education / mobilization intervention was initiated in 2004 and the evaluation was completed in 2007. THE COMMUNITY EDUCATION / MOBILIZATION INTERVENTION Aim: The overall aim of this intervention was to promote community knowledge, attitudes, and practices for safe motherhood, and thus contribute to the prevention of obstetric fistula and other maternal and infant complications. If the strategy used is deemed successful, the model could potentially be scaled-up nationwide and, with adaptations, used in other countries. Summary: The study intervention was designed based on a successful community mobilization efforts implemented by the Eritrean MOH in other zones of the country. The main focus of the strategy consisted of training local health center staff and female and male Maternal Health Volunteers (MHVs) to work with community members on safe motherhood issues, including utilization of antenatal care, malaria prevention, recognition of danger signs during pregnancy, labor, and delivery, the importance of prompt referral when complications occur, and the importance of using skilled birth attendants. The MHVs participated in a 10-day training course and were supervised and supported by local health center staff. The volunteers held participatory meetings on safe motherhood issues with women, men, and TBAs in the communities where they live and work. Particular importance was given to working with men, as they are often the primary decision-makers for utilization of health care services and

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spending money for services and transportation to health care facilities. The maternal health volunteers are unpaid, but are reimbursed for expenses incurred during their training, in the form of a daily per-diem payment for each day of training. In addition to these efforts to increase community awareness of safe motherhood and demand for maternity services, the intervention also included efforts to strengthen local health facilities, including training of health workers and infrastructure improvements. Selection of the intervention and control communities: In November-December 2004, Dr. Janet Molzan Turan visited Eritrea and held preliminary meetings with the Eritrean MOH (Minister of Health, Head of the Health Promotion Unit, Head of the Reproductive Health Unit), the UNFPA staff in Eritrea, and a representative from UNFPA headquarters. After the overall strategy was identified, staff members from the MOH HPU and Dr. Turan visited the Northern Red Sea Zone (NRSZ) to meet with local health officials to discuss the project and to visit two potential project communities in the NRSZ (Shieb and Kamchewa). During the community visits exploratory interviews were completed with community leaders and key informants[1] (3 in Shieb and 4 in Kamchewa) and basic data on the community and health facilities were collected (detailed community data forms were completed). Community leaders in both sites expressed interest and willingness to participate in the project and provided valuable information about local conditions and concerns. Based on these visits, Kamchewa was deemed suitable for the project, while Shieb was deemed unsuitable because of seasonal migration of the majority of the population to different areas of the country, presenting difficulties for implementing, monitoring, and evaluating the intervention. Staff of the HPU Unit subsequently visited other potential sites in the country in order to find a community that was comparable to Kamchewa. At the completion of this exercise, Haboro and neighboring kebabis in the nearby Anseba Zone were selected as the comparison areas for the study. The intervention community: Kamchewa is a kebabi in the Northern Red Sea Zone of the country, located in the Afabet Sub-Zone. The central village of Kamchewa is located about 1 hour from the town of Afabet by Land Rover, traveling on a very rough road. The majority of the residents are Muslims and Tigre speakers. There is a government health center located in Kamchewa and the nearest hospital is located in Afabet. However, during most of the intervention period, Afabet Hospital was not equipped to provide cesarean section and women needing this intervention would need to be transported to Keren Hospital, around 3 hours from Kamchewa by Land Rover. Cesarean section only became available at Afabet Hospital in the spring of 2007. The control community: Haboro is a kebabi located in the Anseba Zone of Eritrea, about 5 hours drive by Land Rover from Kamchewa. Similar to Kamchewa, the majority of the residents are Muslims and Tigre speakers. The health facilities nearest to the Haboro population are Haboro Health Center and Filfile Health Station (HS). Both Haboro and Filfile refer complicated cases to Keren Hospital (1.25 hour drive from Filfile and 2.25 hour drive from Haboro on a very rough road) for comprehensive emergency obstetric care. (Keren Hospital is the main referral hospital for Anseba Zone, as well as some areas of the Northern Red Sea Zone, and Gash Baraka Zone.) MATERNAL HEALTH VOLUNTEERS The main focus of the intervention activities was on the training and support of local community members known as Maternal Health Volunteers (MHVs). As described below, the MHVs were trained to hold a series of participatory meetings with their fellow community members regarding safe motherhood and prevention/treatment of obstetric fistula. The focus of the MHVs training

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and work is on prevention of obstetric fistula and other maternal and infant complications through promotion of attitudes and behaviors for safe motherhood. Selection of the MHVs: Following community meetings to discuss the results of the baseline survey (see below), 30 female maternal health volunteers were initially selected to undergo training in the intervention community. After the realization of the need to engage men in the intervention, 30 male MHVs were subsequently selected. The selection of the volunteers was carried out with the assistance of community leaders and community organizations already active in the community (such as the National Union of Eritrean Women (NUEW)). The volunteers were selected by the community using the following criteria defined by the community and the study team. Selection criteria for MHVs included:

respected persons in the community permanent residents of the community literate (preferred but not an absolute requirement) motivated to teach others about safe motherhood willing and able to work to promote safe motherhood on a volunteer basis

Training: The training for the maternal health volunteers (MHVs) was conducted by the Health Promotion Unit of the Eritrean Ministry of Health and the curriculum was based on Community-Based Life Saving Skills (CBLSS) Manual (Tigrinya) developed by the Eritrean MOH [9], which had been adapted from the Home-Based Life Saving Skills (HBLSS) Curriculum of the American College of Nurse-Midwives [10]. Another resource used in the training was the Draft Training Manual for Health Care Providers on Behavior Change Communication for Safe Motherhood developed by the Eritrean MOH in collaboration with UNFPA [11]. The training program also included added content on prevention and repair of obstetric fistula, including topics such as the causes of obstetric fistula, prevention of obstetric fistula, recognizing obstetric fistula when it occurs, resources for fistula repair, recovery after surgery, and reintegration into the community. The initial training courses lasted 10 days and included the following topics (specific fistula-related topics in bold):

Introduction, background, and objectives of the training Women and baby problems Prevention of problems during pregnancy, birth, and postpartum Referral Too much bleeding Sickness with pain and fever Birth delay Swelling and fits Too many children Baby has breathing problems at birth Baby born too small Baby falls sick Women suffering from constant urine leakage after difficult labor How to be a good facilitator of group discussions

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How to use the monthly reporting and evaluation forms, the reference manual, and the discussion guide

Separate 10-day training courses were conducted for around 30 female MHVs (March 2006) and 30 male MHVs (September 2006). The MHVs were provided with a reference manual, a field guide, and flipcharts on ANC, FGM, and Safe Motherhood in the local language (Tigre) to support their work. A refresher training course was held for all MHVs for 5 days during May 2007. Topics emphasized in the refresher training included the importance of using antenatal care (ANC) and delivery services, combating FGM, prevention and repair of obstetric fistula, danger signs during pregnancy and birth, preventing anemia in pregnant women, and how communities can contribute to safe motherhood. The volunteers have basic training to be able to identify women with obstetric fistula in the community and refer them to health services, as well as how to refer women with danger signs during pregnancy, birth, or postpartum. Monitoring and supervision: It was planned that regular supervision and monitoring of the MHVs would be conducted by different levels of the health system, including:

Local: Health workers based at the Kamchewa health center (at least monthly) Sub-Zonal: Doctor in charge of Afabet Hospital (when possible) Zonal: Staff of the NRSZ MOH office (every 3-4 months) National: Less frequent supervisory visits by representatives of the Reproductive

Health Unit and the Health Promotion Unit of the Central MOH in Asmara (every 6 months)

In practice, ongoing regular monitoring and supervision of the MHV activities was conducted by the Head Nurse at the Kamchewa Health Center, supplemented by infrequent joint monitoring visits by representatives from the Central MOH, NRSZ MOH, and Afabet Hospital. Monitoring forms (see Appendix 4) were used by the MHVs and the Kamchewa Head Nurse to record monthly MHV activities and utilization of maternity services during the intervention period, and these forms were submitted to the HPU of the Central MOH for evaluation on a regular basis. Although a checklist for quarterly supervisory visits by the NRSZ MOH office was developed (see Appendix 4), this supervision was never implemented on a regular basis. The NRSZ MOH office is located in Massawa (at least 4 hours from Kamchewa by Land Rover) and visits were hindered by lack of vehicles and fuel, as well as lack of clear delegation of responsibility on this matter. Activity levels: At the times of the supervisory visits and assessments, it was observed that the MHVs were actively organizing and holding discussion groups in their communities. At the time of the mid-intervention assessment in November 2006, 32 groups (20-25 members in each group) had been organized by female volunteers and 3 groups (total of 64 men) had been organized by male volunteers (the male MHVs had only recently been trained). Volunteers attended monthly meetings with the Kamchewa HC health workers, although those living in more distant villages were rarely able to attend. At the time of the final assessment, the MHVs were still active--20 female and 19 male MHVs reported conducting discussion groups during May 2007. Promotion of ownership by the local community: Several methods were used to promote ownership of this project by the local community. The local community leaders in Kamchewa were consulted and involved every step of the way—from the initial visit for selection of the

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project site to the final assessment visits. After the selection of Kamchewa as the intervention community, community leaders and other groups in the community (married men, elder women, and TBAS) were involved in baseline focus group discussions and in-depth interviews on their knowledge, attitudes, behaviors regarding safe motherhood, as well as their suggestions for improving maternal health in their community. Following the analysis and write-up of the baseline data, the survey and focus group findings were presented at a community meeting. At this meeting the community supported the idea of training MHVs and was active in the selection of the persons to serve as MHVs. Community discussions were also held at the time of the supervisory visit in July 2006. The mid-intervention assessment included meetings with community leaders in Kamchewa and Afabet. The community leaders meeting in Afabet involved several groups that are active at the community level in Kamchewa (the Sub-Zobal administration, the Ministry of Education (MOE), the National Union of Eritrean Women (NUEW), the National Union of Eritrean Youth & Students (NUEY&S), the political party (PFDJ), and Afabet Hospital), and the participants stated their support of the project and promised to carry out specific duties to enhance the effectiveness of the project. Focus group discussions and in-depth interviews with community members were repeated at the time of the final assessment. Throughout the life of the project, efforts were made to implement the suggestions of the community members for increasing the impact of the project. IMPROVING THE QUALITY OF MATERNAL HEALTH SERVICES As the project developed, the team felt that in addition to the community education and mobilization efforts, it would be essential to strengthen the local health services in the intervention area so that they would be able to meet increased demands of the community and provide high quality maternity services. Efforts in this area included training of local health workers in communication skills and efforts to improve and upgrade infrastructure for maternity services and transportation between Kamchewa and Afabet Hospital. Training for health workers in interpersonal communication (IPC) skills: In September of 2006, 16 health workers from Kamchewa Health Center and Afabet Hospital participated in a 6-day training on interpersonal communication skills for provision of maternal and child health services. The training was located in Afabet led by the Health Promotion Unit of the MOH. Topics covered in the training included:

The role of IPC in the provider-client interaction. Evaluation of own interpersonal skills with clients Time line for a pregnant woman from pregnancy to delivery The role of health workers in saving the lives of mothers and children Linking training to performance Key importance of management and IPC in health services Development of an action plan for improvement of ANC and delivery services

Strengthening of local health infrastructure: Although it was planned to make some small infrastructure improvements to Kamchewa Health Center during the pilot project period, only a few were realized. Importantly the ambulance used by the Kamchewa Health Center, which was not in working condition at the time of the initial assessment, was repaired with project funds. However, at the time of the mid-intervention assessment, the Kamchewa ambulance driver had been transferred to another location. Although at the time of the mid-intervention assessment in November 2006 the local sub-zonal administration in Afabet agreed to take responsibility for making sure that Kamchewa has a working ambulance and driver, Kamchewa

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did not have consistent ambulance service during the pilot project period. Other infrastructure needs of Kamchewa HC, such as a water tank, an incinerator, a placenta pit, the assignment of a midwife, and a fence for the HC, were not met during the pilot project period. The strengthening of Afabet Hospital to provide comprehensive EmOC was also seen as crucial to the success of the intervention in Kamchewa, as women who are referred from Kamchewa with obstetric emergencies often need to get the blood transfusion and/or cesarean section as soon as possible. However, this could not be accomplished until late in the project period with the remodeling of Afabet Hospital to shift MCH services to the main hospital compound and the arrival of an Ob/Gyn specialist, an anesthesiologist, a midwife, an OR nurse, and another nurse from Medicins du Monde in December 2006. Cesarean section services began to be offered at Afabet Hospital in the spring of 2007. COST OF THE INTERVENTION According to data collected by the Health Promotion Unit of the MOH, the cost of the maternal health volunteer intervention (excluding the costs of the evaluation study) is presented in the table below. The total cost of initial and refresher trainings and materials for 60 MHVs was around $37,000 dollars. In addition, the cost of regular supportive supervision by the NRSZ MOH office is estimated at around around 7,000 Nakfa per supervisory trip, for a total of 28,000 Nakfa per year ($1,867). Financial expenditures for the Kamchewa Maternal and Child Health and Prevention of Obstetric Fistula Project Activity Financial expenditure description Budget

(Nakfa) US $ equivalent

1 Community demand creation meeting with community leaders

* Perdiem Facilitators 6 staff X 200 Nfa X 5 days * Transport 1 car X 2300 X 7 days * Refreshment

6,000 16,100 300

2 Initial training of maternal health volunteers

* Perdiem Facilitators 5 staff X 200 X 12 days * Transport 1 car X 2300 X 12 days * Perdiem MHV 60 X100 Nfa X 10 days * Refreshment

12,000 27,600 60,000 12,000

3 Materials T-Shirts Bags Stationary Scarves Print materials (reference manuals)1 Reporting format paper print

250,000

Sub total 384,000 Nakfa

$25,600

1 Reference manual for MHVs provided free of charge from the MOH.


Refresher Training (Held Twice) Activity Financial expenditure description Budget Remarks 1 Refresher training of

maternal health volunteers

* Perdiem Facilitators 5 staff X 200 X 8 days X 2 times * Transport 1 car X 2300 X 10 days X 2 times * Perdiem MHV 60 X100 Nfa X 7 days X 2 times * Refreshment X 2 times

16,000 46,000 84,000 24,000

Sub total 170,000 Nakfa

$11,333

Grand Total 554,000 Nakfa $36,933 EVALUATION DESIGN AND METHODS: Overview: Evaluation of the project was conducted using a quasi-experimental study design (nonequivalent group pretest-posttest) in order to evaluate the impact of the community intervention on knowledge, attitudes, and practices related to safe motherhood and prevention/treatment of obstetric fistula. The evaluation design included: 1) baseline data collection in one intervention and one control community, 2) implementation of intervention activities in the intervention community, 3) a mid-intervention process evaluation, and 4) final assessment data collection in intervention and control communities one year after initiation of the intervention. 1. Aims of the evaluation research Aim 1: To determine whether or not the proposed intervention increases knowledge of danger signs for pregnant, delivering, and postpartum women (especially early rupture of membranes, prolonged labor, and obstructed labor) in the intervention community as compared to the control community. Aim 2: To determine whether or not the proposed intervention increases birth preparation in the intervention community as compared to the control community. Aim 3: To determine whether or not the proposed intervention increases the use of ANC services and health facility delivery services in the intervention community as compared to the control community. Aim 4: To determine whether or not the proposed intervention increases knowledge of the causes, ways to prevent, signs, and resources for repair for obstetric fistula in the intervention community as compared to the control community. Evaluation study activities and timeline: The main activities of the evaluation study are presented in chronological order below, and graphically in Figure 1.


Selection of intervention and control areas: • Preliminary visits to potential intervention and control communities in the NRS and

Anseba Zones of Eritrea in Nov-Dec 2004 • Selection of Kamchewa as the intervention community and Haboro as the control

community Health facility assessments:

• Health facility assessments in the intervention and control communities in February 2005 Baseline data collection:

• Baseline survey, focus groups, and in-depth interviews in intervention and control areas during March-April 2005

Feedback and discussion with the community

• Feedback and discussion with the intervention community and selection of persons to be trained as maternal health volunteers (MHVs)

Training of MHVs:

• Training of first group of MHVs (29 women and 1 man) in March 2006 • Training of second group of MHVs (28 men and 1 woman) in September 2006 • Refresher training in May 2007

Monitoring and supervision:

• Supervisory visit from the central level MOH in July 2006 • Mid-intervention assessment conducted in November 2006

Final data collection:

• Final survey, focus groups, and in-depth interviews in intervention and control areas during June 2007


Figure 1. Evaluation Study Activities and Timeline Activity

Oct-Dec 2004

Jan- Mar 2005

Apr- June 2005

July-Sept 2005

Oct-Dec 2005

Jan- Mar 2006

Apr- June 2006

July-Sept 2006

Oct-Dec 2006

Jan- Mar 2007

Apr- June 2007

July-Sept 2007

Initial selection of intervention and control areas

X

Safe motherhood health facility assessments

X

Baseline data collection

X

Feedback and discussion with the intervention community

X

Training of female MHVs

X

Intervention activities in Kamchewa

X X X X X X

Supervisory visit from Central Level MOH

X

Training for health workers on interpersonal communication

X

Training of male MHVs

X

Mid-intervention assessment

X

Refresher training for MHVs

X

Final data collection

X


Methods Baseline data collection methods: Methods for collection of baseline data included 1) a cross-sectional survey of women who gave birth in the past 12 months 2) focus groups with community members, and 3) one-on-one qualitative interviews with traditional birth attendants (TBAs). These were conducted in the Kamchewa (intervention) and Haboro (comparison) areas of Eritrea during March-April 2005. A total of 466 women who had given birth in the past 12 months (216 in the Kamchewa area and 250 in the Haboro area) were interviewed by trained female interviewers in Tigre or Arabic language using a semi-structured questionnaire. Focus groups were conducted with community leaders, married men, and older women (mothers and mothers-in-law of women of reproductive age) in both the intervention and comparison communities. TBAs (3 in the intervention area and 8 in the comparison area) participated in one-on-one qualitative interviews. In addition, a safe motherhood health facility assessment was conducted by the study team in February 2005, prior to the commencement of intervention activities. This assessment included the health facilities that would be used by communities involved in the study, focusing specifically on the safe motherhood services that people will be encouraged to use as part of the intervention. A checklist for assessment of the services and resources for safe motherhood was developed for this study, based on a larger checklist used for assessing all reproductive health services as part of the Reproductive Health Follow-up Study conducted in Eritrea in 2004. The senior health worker present at the facility was interviewed in order to fill out the checklist. In addition, facilities, records, information, education, and communication (IEC) materials, and available supplies were examined by the assessment team, whenever possible. Each facility assessment took approximately one and a half hours to complete. Mid-intervention assessment methods: The mid-intervention assessment, conducted in November of 2006, consisted of interviews and meetings with key informants, community meetings, observation of MHV-led discussion groups, and repetition of the safe motherhood health facility assessments. Individual interviews / meetings were conducted with many of the key persons involved in the project at different levels including the Northern Red Sea (NRS) Zone MOH Director, the nurse in charge of the Kamchewa Health Center (HC), the doctor in charge of Afabet Hospital, and Haboro HC health workers. Group community meetings were held with 1) Kamchewa community leaders, 2) Kamchewa maternal health volunteers (MHVs), and 3) Afabet sub-Zobal leaders. Two women’s groups in Kamchewa, led by trained female MHVs, were observed by different members of the assessment team. Safe motherhood facility assessments were conducted at Kamchewa HC, Afabet Hospital, and Haboro HC. These assessments were conducted using the same form that was used to assess these facilities before the intervention began in February 2005, with the addition of a page for collection of monthly antenatal and delivery service statistics for 2005 and January-October 2006. Final assessment methods: Methods for collection of final assessment data were essentially the same as the baseline data collection methods, including a cross-sectional survey of women who gave birth in the past 12 months (different women than were surveyed at baseline) and focus groups and one-on-one interviews with community members and TBAs. In addition, focus groups were held with male and female MHVs in the Kamchewa area to obtain their feedback and perspectives on the intervention activities. These final data collection activities were conducted in the Kamchewa (intervention) and Haboro (comparison) areas of Eritrea during June 2007. The final assessment also included collection and review of ANC and delivery service statistics from health facilities in the intervention and control areas.


Survey: A total of 378 women who had given birth in the past 12 months (129 in the Kamchewa area and 249 in the Haboro area) were interviewed by trained female interviewers in Tigre or Arabic language using a semi-structured questionnaire. Although the areas included and the sampling and recruitment methods used were the same as in the baseline survey (refer to Baseline Report), the sample size attained for the final survey in Kamchewa was significantly lower than that attained at baseline (129 at final assessment vs. 216 at baseline). Members of the survey team attributed the lower sample size attained at the time of the final assessment to reduced fertility due to drought and poor economic conditions in the area. The questionnaire used in this survey is presented in Appendix 1. Focus Groups and One-on-One Interviews: A total of 18 focus groups were conducted with community leaders (2 groups), married men (6 groups), and older women (7 groups of mothers and mothers-in-law of women of reproductive age) in both the intervention and comparison communities at the final assessment. Seven TBAs participated in small group discussions or one-on-one qualitative interviews. Characteristics of the participants in these focus groups and interviews are presented in Appendix 3. The moderator’s guides for the focus groups of Maternal Health Volunteers are included in Appendix 2 while the guides for the other types of groups can be found in the baseline report. FINDINGS Summary of baseline findings: At baseline, women who had given birth in the past 12 months in the intervention and comparison communities were found to be similar in terms of important socio-demographic characteristics, such as age, education, ethnic group, language, religion, and number of living children. On the other hand, there were some interesting differences between the two groups in terms of lifestyle, characteristics of husbands (age and occupation), and age at first pregnancy and birth. The results show that, in general, knowledge, attitudes, and practices (KAP) related to safe motherhood were more favorable in the Haboro area, as compared to the Kamchewa area at baseline, and the differences were quite large and consistent for most of the variables examined. On the other hand, there was still substantial room for improvement in many of the key indicators related to safe motherhood and prevention/treatment of obstetric fistula in both Kamchewa and Haboro areas. For example, in both areas over 96% of women delivered at home and the percentages with skilled assistance (doctor, nurse, or associate nurse) at the delivery were 4.2% in the Kamchewa area and 7.7% in the Haboro area (not a statistically significant difference). Although many people in both areas had heard about obstetric fistula, few knew that it is most often caused by prolonged and/or obstructed labor and few had specific knowledge about the possibilities for fistula repair. The qualitative data collection provided valuable information on reasons for the preference for home delivery in the study areas and how obstetric complications are usually handled at home. Mid-intervention assessment summary: The results of the mid-intervention assessment were quite encouraging. In particular, high motivation and activity levels of the trained MHVs in the community and substantial increases in pregnant women’s use of ANC and HF delivery services at Kamchewa HC were observed. Examination of trends in safe motherhood service statistics at Afabet Hospital (near to Kamchewa) and Haboro HC (control area) did not reveal similar large increases in utilization of ANC and HF delivery services. This suggested that the increases in maternity service utilization may in fact be due to the community intervention. However, community leaders, the MHVs, and the assessment team agreed that the achievements in Kamchewa, though impressive, were not sufficient, especially in the use of HF


delivery services. The majority of women in Kamchewa still gave birth outside the health facility without the benefit of skilled attendance. The assessment activities revealed that the project still faced some challenges including: 1) difficulty attending monthly meetings for MHVs living in more distant villages, 2) continuing lack of support for the project, even opposition in some cases, from some TBAs, 3) reluctance by some families to have childbirth attended by a male health worker, and 4) continuing need for improvements in infrastructure and availability of maternity services offered by the Kamchewa HC. Specific suggestions of the community leaders and the MHVs for strengthening the project included translation of training materials into Arabic, provision of frequent refresher training for the MHVs, more inclusion of community leaders in project activities, and placing of another female health worker to attend deliveries at Kamchewa HC. It was recognized that supporting the community in identifying and solving their own problems is critical for the establishment of community ownership and sustainability of the project. FINAL ASSESSMENT FINDINGS The main purpose of this report is to present the final assessment findings. This includes the findings from the final survey of women who gave birth in the past 12 months, the focus groups and one-on-one interviews with community members, and the review of health facility service statistics. In order to put the final survey findings into appropriate context, most results are presented in comparison to the levels at baseline. SURVEY FINDINGS Social and demographic characteristics: As presented in Table 1 below, many of the social and demographic characteristics of the women in the two study areas were very similar, as they were at baseline. The women in the two areas were similar in terms of age (mean age around 28 years), main language spoken (Tigre), religion (Muslim), and marital status (around 98% married and living with their husband). They were also similar in terms of obstetric history, including mean number of lifetime pregnancies (3.99 in Kamchewa and 3.79 in Haboro), mean number of living children (3.39 in Kamchewa and 3.45 in Haboro), and the proportion with one or fewer live births (21.7% in Kamchewa, 18.5% in Haboro). Median ages of first pregnancy (18 in both areas) and first birth (19 in both areas) were also very similar. However, there were some significant differences that may have implications for interpreting the study findings. Although the proportion of women with no education decreased significantly in both areas as compared to the baseline, Haboro had a significantly higher proportion of women with some education (including female literacy courses) at the time of final assessment (70.7% vs 58.9%, p value= .021). Female literacy courses appear to have made a large contribution to women’s education in both areas over the time period, with around 41% of survey participants having attended such a course at final assessment, compared to 27% at baseline. Similar to the baseline findings, other differences between the two areas at final assessment included the proportion living a nomadic or semi-nomadic lifestyle (14% in Kamchewa, versus 2% in Haboro) and the proportion with a husband in the Eritrean Army (11.7% in Kamchewa vs. 49.0% in Haboro). Perhaps related to this finding, the mean age of husbands was also somewhat higher in Kamchewa, compared to Haboro.


Table 1. Socio-Demographic Characteristics of Women Giving Birth in the Past 12 Months by Study Group at Final Assessment (June 2007) Variable Total

(N=378) Kamchewa (n=129)

Haboro (n=249)

Statistical Test#

Mean age

27.66 27.71 27.64 t=.101, p=.920

% < 25 years of age

31.0 30.2 31.3 χ2=.155, p=.925

% using Tigre language most

100 100 100

% Tigre ethnic group

100 100 100

% Muslim

100 100 100

% with some education1

66.7 58.9 70.7 χ2=5.296, p=.021

% nomadic or semi-nomadic

6.1 14.0 2.0 χ2=21.220, p=.000

% currently living with husband

98.1 98.4 98.0 χ2=.098, p=.7542 Fisher’s Exact = 1.000

Mean age of husband

41.03 43.00 40.04 t=2.76, p=.006

% husband currently working

90.3 87.5 91.7 χ2=1.70, p=.191

% with husband who is a soldier

36.3 11.7 49.0 χ2=50.66, p=.000

% with job that earns money

4.0 1.6 5.2 χ2=3.03, p=.082

Mean number of pregnancies

3.86 3.99 3.79 t=.834, p=.405

Mean number of living children

3.43 3.39 3.45 t=-.297, p=.766

% with one or fewer live births

19.6 21.7 18.5 χ2=.534, p=.453

Mean age of first pregnancy

18.63 18.84 Median:18 Range: 14-30

18.53 Median:18 Range: 14-29

t=.805, p=.4223

Mean age of first birth

19.59 Median: 19 Range: 15-30

19.75 Median: 19 Range: 15-30

19.50 t=1.057, p=.2923

# Chi-square test for categorical variables and t-test for continuous variables, Fisher’s Exact Test for 2x2 tables with small cell sizes; a p value <.05 is considered a statistically significant difference 1 Any formal education, including female literacy courses (but not including Koran courses). 2 1 or more cells expected value < 5 3 Equal variances not assumed.


Participation in the Intervention: In Kamchewa (the intervention area) only, women also responded to questions about their awareness of and participation in the Maternal Health Volunteer intervention (See Table 2 below). In general awareness of the program among those surveyed was high, with 89% having heard of the MHVs and around 90% of those who had heard about it actually having participated in discussion groups led by a MHV. The median number of meetings attended for those who did participate was 10 meetings (range 1-6). Around 25% of those who had heard of the intervention stated that their husband had attended a MHV discussion group. Table 2: Awareness of & Participation in the Maternal Health Volunteer Groups in Kamchewa Variable

Percentage of Kamchewa respondents (n= 129)

% who have heard of MHV 89.1% (115 women)

% who have participated in discussion groups led by MHV (n=115)

89.6 % (103 women)

% who have heard of MHV and talked to someone who participated (n=115)

79.1%

Median # of meetings attended (n=99) Median = 10 Range= 1-6

% whose husband’s participated in meetings (n=115)

25.2% (29 men)

% rating the MHV program “very helpful” (n=115)

87.0% (100 women)

Levels of Key Indicators: Given the generally better levels of many safe motherhood knowledge, attitude, and practice indicators in Haboro compared to Kamchewa at baseline, it makes most sense to compare change from baseline to final assessment separately for the two communities, and to assess whether change has been greater in one community or the other. For this reason, results for the final survey by itself are not presented in detail in the body of this report. However, detailed tables presenting results of the final survey and comparing the intervention and control areas at the time of the final assessment are included in Appendix 5 for reference. The following tables and graphs summarize change in key indicators from baseline to final in the two communities. For categorical variables, the Breslow-Day Test was used to compare the amount of change in the two communities. In this test a p value <.05 indicates that the odds ratios (ORs) for the two areas are significantly different from one another. For continuous variables, ANOVA was used and a p value of <.05 indicates that the interaction term for area X timing is significant, i.e., the change from baseline to final is significantly different for the two areas.


Use of Antenatal Care (ANC) and Other Sources of Support during Pregnancy The data on antenatal care indicate significant improvements in use of antenatal care and the support that women received during pregnancy over the study period in the intervention area, as compared to the control area. All the indicators in Table 3 below show significant improvements in Kamchewa and no significant change in Haboro. For some indicators, such as any use of ANC, Kamchewa appears to have “caught up” to the higher levels of Haboro, whereas for other indicators, such as completion of four or more ANC visits during pregnancy, Kamchewa greatly surpassed Haboro at the time of the final assessment. Changes in a few key ANC indicators are also illustrated in Figure 2.

Table 3. Changes in Antenatal Care Indicators (N=844) Indicator

Intervention Area: Kamchewa

Control Area: Haboro Statistical Test comparing change**

Baseline (n=216)

Final (n=129)

Baseline (n=250)

Final (n=249)

Any use of ANC (%) 74.9 99.2* 94.0 91.5 29.817, p=.000

Mean number of ANC visits1

2.91 5.37* 3.67 3.72 F=113.357, p=.000

Four or more ANC visits1 (%)

24.7 80.2* 56.6 51.8 65.722, p=.000

Initial ANC visit in the 1st trimester1 (%)

7.4 28.6* 8.5 8.8 10.689, p=.001

Treated “very well” at the ANC facility (%)

13.0 60.6* 34.9 30.3 54.259, p=.000

Got help with her work from her husband during pregnancy (%)

36.4 58.6* 52.8 54.5 8.241, p=.004

1 Among those who had at least one ANC visit. * p value from chi-square or t-test comparing baseline and final is < .05, indicating a significant change in the indicator over time. ** Breslow Day Test for categorical variables or ANOVA for continuous variables. Knowledge of Danger Signs Table 4 shows changes in knowledge of selected pregnancy and birth danger signs in the two communities from baseline to final assessment. For pregnancy, the percentage of women who knew any pregnancy danger sign increased significantly in Kamchewa, while there was a significant decrease in this indicator in Haboro. On the other hand, knowledge of many specific pregnancy danger signs appears to have improved in both communities over the study period. However in most cases, the improvement in knowledge of these signs from baseline was greater in Kamchewa than it was in Haboro. For birth danger signs, on the other hand, knowledge of most of the danger signs show significant improvement in Kamchewa, but no significant change in Haboro. Of importance for obstetric fistula, knowledge of prolonged labor as a danger sign increased significantly in Kamchewa (but only to 27% of women!), but not in Haboro. There was no change in the relatively low percentages knowing obstructed labor (described as “pushing with strong labor pains for more than one hour and baby is not born”) in either community.


Table 4. Changes in Knowledge of Danger Signs (N=844) Indicator



Baseline (n=216)

Final (n=129)

Baseline (n=250)

Final (n=249)

Pregnancy Danger Signs Knows any pregnancy danger sign (%)

51.9 72.9* 94.4 81.1* 35.323, p=.000

Knows early membrane rupture (%)

0 27.9* 1.2 30.1* 2.108, p=.147

Knows bleeding (%) 9.3 84.5* 14.0 61.0* 18.316, p=.000

Knows swelling (%) 4.6 51.2* 23.2 46.2* 25.722, p=.000

Knows early labor pains (%)

5.6 34.9* 7.2 24.5* 3.001, p=.083

Knows fever (%) 25.0 57.4* 48.8 58.6* 11.288, p=.001

Knows fits (%) 5.6 38.8* 9.2 28.1* 5.671, p=.017

Knows persistent headache (%)

22.2 50.4* 36.4 37.8 16.081, p=.000

Knows a woman should see a trained HW if danger sign during pregnancy

81.5 90.7* 95.6 98.8* 0.517, p=.472

0102030

405060

708090

100%

of w

omen

baseline final baseline final

Figure 2. Change in ANC Indicators

KamchewaHabero

% using any ANC

% treated very well at ANC visit


Table 4. Changes in Knowledge of Danger Signs (N=844) Indicator



Baseline (n=216)

Final (n=129)

Baseline (n=250)

Final (n=249)

Birth Danger Signs Knows any birth danger sign (%)

42.1 61.2* 65.9 55.6* 17.094, p=.000

Knows prolonged labor (%)

13.0 27.1* 23.2 25.4 5.163, p=.023

Knows obstructed labor (%)

7.4 7.0 11.6 9.7 0.070, p=791

Knows too much bleeding (%)

19.0 43.4* 38.0 37.1 15.857, p=.000

Knows fever (%) 11.6 30.2* 18.8 25.8 4.872, p=.027

Knows retained placenta (%)

3.7 7.0 12.8 13.7 1.099, p=.294

Knows cord prolapse (%)

3.7 9.3* 8.0 3.6* 8.997, p=.003

Knows a woman should see a trained HW if danger sign during delivery

79.4 93.8* 96.8 97.8 2.624, p=.105

* p value from chi-square or t-test comparing baseline and final is < .05, indicating a significant change in the indicator over time. ** Breslow Day Test for categorical variables or ANOVA for continuous variables. Birth Preparations One aim of the intervention was to increase the plans and preparations that women and families make for an upcoming birth, which will allow them to respond quickly in case danger signs do occur and contribute to prevention of maternal and infant complications. The results indicate that the percentages making birth preparations increased greatly in both areas over the study period (mainly those identifying the nearest health facility where they could go if there were problems during the birth) and that the intervention area did not improve more than the control area on these indicators.

Table 5. Birth Preparations (N=844) Indicator



Baseline (n=216)

Final (n=129)

Baseline (n=250)

Final (n=249)

Made any birth preparations (%)

39.8 85.3* 26.5 76.6* 0.011, p=.916

Identified nearest health facility (%)

13.9 50.4* 10.0 44.8* 0.156, p=.693


Arranged transportation (%)

5.6 17.1* 7.2 11.7 2.169, p=.141

Set aside money (%) 3.7 16.3* 3.6 10.5* 0.676, p=.411

Decided who would go along (%)

16.7 21.7 4.8 16.5* 5.627, p=.018

Talked with a trained HW (%)

0.9 8.5* 8.4 12.5 5.863, p=.015

Decided who would assist (%)

6.9 9.3 15.7 29.8* 1.233, p=.267

Husband helped with birth preparations (%)

18.1 34.1% 14.4 30.5% 0.096, p=.757

* p value from chi-square or t-test comparing baseline and final is < .05, indicating a significant change in the indicator over time. ** Breslow Day Test for categorical variables or ANOVA for continuous variables. The Birth Women responding to the questionnaire also answered questions about the labor and delivery that they had experienced in the past 12 months. Unfortunately, several of these questions were mistakenly skipped for 50 women (45 in Haboro and 5 in Kamchewa) at the time of the final assessment, due to a wrong skip instruction in the questionnaire that was not corrected on some copies. In addition, those who skipped this question were all women who said that they did not make any plans or preparations for the upcoming birth. Thus, the results in Table 6 must be viewed with great caution. However, even if we assume that all 50 of those women delivered at home without a skilled attendant (in this case the proportion with health facility delivery at the final assessment becomes 45% in Kamchewa and 12.4% in Haboro), it appears that there was a significant increase in health facility delivery in Kamchewa over the study period, compared to a smaller increase in Haboro. The large increase in the proportion who said they were treated “very well” by their birth attendant in Kamchewa, compared to a significant decrease in that indicator of the quality of maternity services in Haboro over the same time period, is also notable. There were not significant differences between areas or time periods in the proportion with prolonged labor, the proportion transferred during the birth, and the proportion that lost an infant to stillbirth or a later infant death. It must be kept in mind that the sample size is too small to detect these rare outcomes and that those interviewed were women who survived. Although it is not really indicative of the level of maternal mortality, the proportion of women who said they knew of a maternal death in their community in the past 12 months decreased in Kamchewa (ns), while there was a significant increase in this proportion in Haboro. This proportion was also significantly higher in Haboro than it was in Kamchewa at the time of the final assessment (See Appendix 5.)

Table 6. The Birth (N=794) 2 Indicator



Baseline (n=216)

Final (n=124)

Baseline (n=250)

Final (n=204)

Skilled birth attendant (%)1

4.2 46.7* 7.7 15.2* 22.159, p=.000

Health facility delivery 3.2 46.8* 3.6 15.2* 9.113,


(%) p=.003 Treated “very well” by birth attendant (%)

31.6 52.0* 44.8 32.8* 20.225, p=.000

Experienced a problem (%)

34.4 13.3* 11.2 7.8 3.475, p=.062

Labor > 12 hours (%) 16.5 15.0 12.2 10.9 0.001, p=.974

Transferred during the birth (%)2

3.2 3.2 3.3 3.2 0.000, p=.991

Stillbirth or infant death (%)2

1.4 3.1 2.8 2.0 1.427, p=.232

Knows of a maternal death in community in past 12 months (%)2

22.5 18.6 16.5 28.0* 6.686, p=.010

1 Doctor, nurse, or midwife (does not include traditional birth attendants). 2 Data on all women (N=844) is available for these variables. * p value from chi-square or t-test comparing baseline and final is < .05, indicating a significant change in the indicator over time. ** Breslow Day Test for categorical variables or ANOVA for continuous variables. Postpartum Health and Family Planning Overall, there were changes in postpartum health and family planning knowledge and behaviors in both areas (See Table 7). In Kamchewa there was a significant increase in the proportion of women who said that they visited a health facility after the birth, while in Haboro there as a significant decrease in this proportion. On the other hand, among those women who did visit a HF, there was a significant increase in the proportion who visited for their own health (not just for the infant’s health) in Haboro, whereas this proportion did not change significantly in Kamchewa. The proportion who said they wanted to do something to prevent or delay the next birth increased significantly in Kamchewa, whereas in Haboro there was no significant change from the already high proportion (over 80%) stating this desire. Both areas experienced large and significant increases in the proportion of women who know of any family planning method, although the increase was greater in Kamchewa than in Haboro. The percentage currently using a FP method at the time of the interview remained under 10% in both areas, but Kamchewa experienced a significant increase, whereas Haboro did not.

Table 7. Postpartum Health and Family Planning Indicator



Baseline (n=216)

Final (n=129)

Baseline (n=250)

Final (n=249)

Health facility visit after the birth (%)

66.4 76.7* 78.8 58.2* 21.803, p=.000

HF visit for own health after birth (%)1

45.4 33.3 27.1 39.3* 8.829, p=.003

Wants to delay/ prevent next pregnancy (%)

62.0 72.7* 81.9 85.9 0.301, p=.583


Knows any FP method (%)

8.8 51.2* 22.0 45.8* 13.239, p=.000

Currently using a FP method

2.3 9.4* 4.4 6.5 2.578, p=.108

1Out of those who visited a HF after the birth (Kamchewa N=240, Haboro N=337), those who stated the reason for the visit as for maternal health or for both maternal and child health. * p value from chi-square or t-test comparing baseline and final is < .05, indicating a significant change in the indicator over time. ** Breslow Day Test for categorical variables or ANOVA for continuous variables. Obstetric Fistula One important aim of the intervention was to increase awareness and knowledge regarding obstetric fistula, its prevention, and its treatment (See Table 8). Interestingly the proportion who said they had heard about fistula (described as “women who constantly lead urine and/or feces after a delivery”), remained about the same in the intervention area, while there was a significant decrease in the control area. The proportion who said they knew a woman with fistula personally increased significantly in Haboro, whereas this proportion also remained stable in Kamchewa. On the other hand, there was a significant decease in the proportion who said they had experienced this problem themselves in Kamchewa, compared to no change in Haboro. Knowledge of prolonged labor as a cause of fistula increased significantly in both areas, while the proportion stating FGM as a cause of fistula increased in Kamchewa but decreased in Haboro. Importantly, the proportion who stated HF delivery as a way to prevent fistula increased in both areas, with a greater increase from baseline and level at the final assessment in Kamchewa as compared to Haboro (62% vs. 47%). In addition the proportion who knew that delivery with a skilled attendant is a way to prevent fistula increased significantly in Kamchewa, whereas there was a non-significant decrease in Haboro. The proportions who knew that fistulas can be repaired were already high in both areas at baseline (over 85%) and this proportion remained steady in Kamchewa, whereas there was a decrease in Haboro. The proportions who said a man should divorce or live separately from a woman with fistula if they have no children together was slightly lower in Kamchewa than Haboro at both baseline and final assessment (ns), but neither area had a significant change in this attitude over the study period.

Table 8. Obstetric Fistula Indicator



Baseline (n=216)

Final (n=129)

Baseline (n=250)

Final (n=249)

Heard about women with fistula (%)

48.1 49.6 87.6 66.3* 17.016, p=.000

Know a woman with fistula (%)

5.2 5.6 4.0 10.4* 2.269, p=.132

Experience fistula herself (%)

11.8 2.4* 1.6 0.4 0.050, p=.822

Knows prolonged labor as a cause (%)

18.9 38.8* 37.6 59.4* 0.130, p=.718


Says FGM is a cause of fistula (%)

6.6 13.2* 40.4 28.5* 9.787, p=.002

Knows delivery in HF to prevent fistula (%)

32.2 61.7* 29.3 47.4* 2.202, p=.138

Knows skilled attendant to prevent fistula (%)

14.5 31.3* 30.1 24.9 13.888, p=.000

Knows fistula can be treated

85.9 89.6 98.0 93.4* 6.748, p=.009

Says man should divorce if no kids (%)

6.9 9.3 10.8 13.7 0.011, p=.917

* p value from chi-square or t-test comparing baseline and final is < .05, indicating a significant change in the indicator over time. ** Breslow Day Test for categorical variables or ANOVA for continuous variables. SUMMARY OF FOCUS GROUP AND INTERVIEW FINDINGS The following is a brief summary of the findings from the focus groups and qualitative interviews conducted at the time of the final assessment. The numbers and types of groups, as well as the characteristics of the participants are presented in Appendix 3.

Focus Groups with Maternal Health Volunteers In the Kamchewa area, one focus group with female volunteers and one group with male volunteers were conducted, including a total of 20 female and 10 male MHVs. Training: In terms of their training, both groups found the training sessions on the importance of ANC and delivering in health facilities to be the most useful sessions. The female MHVs appreciated the fact that they could learn something in the training program, teach it to women, and then see its impact on the women. The male MHVs especially appreciated the allowances they received during the trainings, which helped to make up for being absent from work. The male MHVs suggested that refresher courses be held every 2 months, while the female MHVs suggested a refresher course every 6 months. Male MHVs also requested that the training materials be made available in Arabic, rather than Tigre, since many of them do not read Tigre. (Interestingly, as an effect of the widespread female literacy programs in Eritrea, it appears that more women than men in this area are literate in Tigre.)

• “We also benefited because we got the chance to learn much, and transferring what we have learned and seeing its outcome on the women makes us feel good. In the past women died for lack of knowledge but now things are improving.” Female MHV

• “The training given to us by the Ministry of Health two months ago helped us both

financially and increased our knowledge.” Male MHV Experiences leading discussion groups in the community: Female MHVs said that they preferred teaching in larger groups because “different opinions and viewpoints are expressed”. Some of the barriers and difficulties in leading discussion groups included getting women to travel the distance to attend sessions, community members coming late to sessions, and not having pre-scheduled times for sessions. Some male MHVs said that using wedding ceremonies as meeting places was convenient. Female MHVs noted the difficulty in changing the attitudes of women towards FGM. At most they could persuade the women to “stop sewing


after the mutilation” and that most women thought “nothing negative about it”. They also noted that the community referred to them as “those who carry bags and sit hours under the shade”, indicating that people perceived them as being well off, because they could spend time sitting in the shade.

• “One of the problems we faced in this program is that we had no pre-scheduled sessions

with the people and the people are out in the fields doing their routine work, so we had to go to where they work, which is time consuming because they are scattered. ….. And sometimes we do the group discussion at night by candle light.” Male MHV

Suggestions to strengthen the MHV program: The volunteers suggested that having more trained midwives and health assistants in the community would strengthen the impact of this program. The female MHVs called for new expanded training manuals and the male MHVs requested that the Ministry of Health have more ambulances at the health facilities. The MHVs also proposed that pregnant women be admitted to the hospitals prior to their delivery, so that they would be there when strong labor pains began. The female MHVs noted the importance of men as partners in safe motherhood programs; they observed that initially, before men were trained as MHVs, many males in the community objected to the program.

• “Before the men were also taught, they used to oppose the idea of their women going to health centers, but later after 30 men were trained, they became very supportive.” Female MHV

Focus Groups with Other Community Members Community members, including married men, elder women, and TBAS, also participated in focus groups as part of the final assessment. Their views on the safe motherhood issues included in the discussion guides are summarized below. Barriers to ANC: The primary hindrances to routine ANC visits, as cited by most participants, were lack of transportation and not knowing that health centers were nearby. Elder women noted that it was not “customary” for the women to receive ANC at health facilities, suggesting that tradition may also prevent women from seeking checkups. Furthermore, one participant in the intervention area noted that some women don’t get check-ups because they are “ashamed of getting pregnant”. However, most groups in both the intervention and control areas noted the importance of health checkups during pregnancy and indicated that women are “concerned” for their health and the health of the baby. Barriers to health facility delivery: In both the intervention and control areas, barriers mentioned included financial and transportation difficulties, being embarrassed to deliver in front of a male health worker, worry about who would take care of their other children, a tradition of relying on TBA assistance, and being uncomfortable in health facilities which don’t permit family presence during labor. In the control area, TBAs noted that there was no nearby health facility. The community leaders, comprised of both men and women, also felt that HF deliveries were complicated by traditional beliefs in “bad omens”. Finally, for many women who started labor at home it became difficult to leave and they were “scared to go out”. (There is a traditional belief that laboring and postpartum women should not be exposed to “outside air”.) On the other hand, in focus groups held in the intervention area, it appeared that community members had more positive attitudes towards HF deliveries. Married men in the intervention area noted that it health facility delivery is to done to ensure “safety for both the mother and child and to prevent any after-delivery diseases”. Community leaders in Kamchewa observed that “since the


awareness trainings have been started by the humanitarian organizations, women have started to deliver in health centers”. Barriers to obtaining emergency obstetric care: Difficulties mentioned in obtaining emergency obstetric care were nearly uniform across the control and intervention areas and the different types of groups. Primarily difficulties had to do with the lack of transportation, such as the lack of an ambulance, bad roads, and the long distances to the referral health facilities. In particular, if the woman developed a complication during the rainy season, participants said that the roads were often impassable due to flooding. Also, financial troubles and finding an adequate companion to accompany the woman to the health facility were problematic. Issues with finding adults to watch over the other children were raised by the elder women and married men. In seeking obstetric care, mothers and families must think about the cost of fuel, transportation, medicine, health cards, and daily fees for hospital beds. Families often did not have enough money to pay for these and had to attempt to pay from their “meager income”. Decision-makers for obstetric care: Regarding making the decision to seek help if a woman experiences a problem during childbirth, virtually all respondents, whether in the intervention or control zones, said that the main decision-maker would be the woman’s husband. If the husband wasn’t at home, then her mother or her husband’s family would be consulted on what to do. According to the participants, the TBA’s role in this decision making process isn’t significant. Knowledge of danger signs: Almost all of the groups identified excessive bleeding, exhaustion, diarrhea, dry lips, narrow hips, delayed delivery of the placenta, fistula, and fever as danger signs during labor and delivery. The control villages classified a change in the color of blood as a danger sign, with elder women in Haboro Tseda saying that “blood changes its color to white”. Additionally, they mentioned long labor in excess of three days as a danger sign. In the intervention region, the elder women identified fever after the birth as being caused by unclean tools causing infection. Among the TBAs in the control region, “womb infection” and “swollen body” were also mentioned as danger signs. TBAs in the intervention area connected the delay in delivery of the placenta to mothers being underweight. Furthermore, they also attributed excessive bleeding to when the “baby’s head is cut with knives used by the TBA”. Perceptions of the quality of care at health facilities: Overall, most participants in the intervention area said that health centers provide “good service,” their only complaint being that the health workers “delay you if you don’t have a card.” Most of the focus groups participants in the control area also described the services at the health center as helpful, clean, and efficient. Reports regarding referral to Keren Hospital were generally positive. However, an exception was the married men participants in Filfile (control area) who described the health workers as “careless”, making the women in pain wait, and not having respect for the patients. Knowledge of obstetric fistula: Some causes of fistula that were mentioned uniformly across the different groups and study areas included female circumcision, under-age marriage, narrow hips, delivering with the assistance of a TBA, delivering alone, malpresentation of the fetus, and “babies born with pressure”. Some TBAs mentioned that causes of fistula also include not urinating prior to labor, midwives or health worker touching the woman’s organs, and an oversized fetus. One TBA in Kamchewa identified midwives with long fingernails as a cause of fistula. The main way to prevent fistula mentioned by the groups was delivery assisted by health workers in health centers. Married men and TBAs in both study areas also suggested that FGM and underage marriage be banned as ways to prevent obstetric fistula. Many participants also knew about fistula repair surgeries being conducted in Mendefera, Dekemhare,


Massawa, Asmara, and Halibet, but traditional remedies such as steam treatments and butter were also suggested as possible treatments. The role of men in supporting women with obstetric fistula: The role of men, specifically the husband, in supporting his wife suffering with obstetric fistula was affected both by whether they shared any children and if the recovery prospects for her were promising or not. TBAs and all the elder women participants in the intervention area called for the husband to support his wife whether or not she had children. On the other hand, elder women in the control areas said that the husband should assist the woman only if they shared children. Interestingly, married men both in the intervention and control areas uniformly called for the husband to help his wife regardless of children. However, one participant group also noted that if the woman cannot fix her fistula through surgery, then the man has the choice to marry again. Married men also noted that men can help to prevent obstetric fistula by “constructing roads” and “solving money problems”. Suggestions to address barriers: Suggestions to improve access to ANC, health facility delivery, and emergency obstetric care from all groups included: 1) improve the transportation infrastructure by asking the government to rebuild the roads and provide ambulances, 2) engage in community fundraising and acquire government subsidies to pay for fuel, and 3) improve telephone and electricity connections. In the intervention areas, there was also a demand for more health assistants, “awareness training”, trained midwives, and health centers. HEALTH FACILITY STATISTICS Health facility statistics on utilization of ANC and delivery services at Kamchewa Health Center in the intervention area and Haboro Health Center in the control area were examined for three time periods: the seven months before the intervention began (Sept 05-March 06), the first seven months of the intervention (April 06-Oct 06), and the second seven months of the intervention (Nov 06-May 07). Although these statistics give an idea of the trend in use of maternity services in each area, the research team felt that the statistics from Kamchewa HC and Haboro HC cannot be directly compared, due to the much smaller catchment population in Kamchewa. As shown in Figures 3 and 4 below, there were very large increases in the numbers of both ANC visit and health facility deliveries at Kamchewa HC in the first seven months of the intervention period. While the amount of maternity services delivered was still higher than baseline, use of these services declined somewhat in the second seven months. Referrals to Afabet Hospital from the Kamchewa HC remained low throughout the entire period, most likely due to the continuing problems with the ambulance (first the ambulance was in disrepair and later the ambulance driver was transferred elsewhere). As for Haboro HC, there were relatively small increases in ANC visits from the 1st to the 2nd time period, but a larger increase in the 3rd period. The number of health facility deliveries at Haboro HC was low overall and remained less than 20 during the last seven month period, considerably less that the number at Kamchewa HC during the intervention period, despite the smaller catchment population of the Kamchewa HC. Referrals to Keren Hospital from Haboro were few during the period examined, again explained due to lack of a vehicle and/or fuel for transporting women.


Figure 3. Kamchewa HC ANC Data

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DISCUSSION The evidence from this evaluation research indicates that the community mobilization strategy used in this pilot project is a very promising one for the promotion of safe motherhood in Eritrea. Alongside urgently needed improvements in transportation, access to emergency obstetric care, and the quality of maternity services, it appears that this type of community effort can make a contribution to improving maternal and infant health in this setting. Particularly impressive are the high activity levels and continued motivation of the Maternal Health Volunteers, the increases in the use of ANC and HF delivery services at the Kamchewa HC, and the significant increases in knowledge and attitudes related to safe motherhood in Kamchewa. It appears that the intervention did have significant positive effects on knowledge of pregnancy and birth danger signs as well as birth preparedness in Kamchewa, but it also appears that there were general improvements in safe motherhood knowledge in other parts of Eritrea during this time period. These improvements may be due to other safe motherhood IEC initiatives of the Eritrean MOH during this period and/or the increased educational level of women in both areas. The proportions making different types of preparations for the upcoming birth increased greatly in both intervention and control areas. However the increases in awareness of pregnancy and birth danger signs were generally greater in Kamchewa (the intervention area) than in Haboro (the control area). Of importance for obstetric fistula, knowledge of prolonged labor as a danger sign increased significantly in Kamchewa, but not in Haboro. Knowledge of early rupture of membranes as a danger sign in pregnancy increased significantly in both communities, while there was no change in the relatively low percentages knowing obstructed labor in either community. There is still considerable room for further improvement in birth preparedness and women’s knowledge of danger signs in both areas—for example awareness of prolonged labor as a danger sign, although greatly improved from baseline, only reached 27% of women in Kamchewa at the final assessment. The results from the survey of women who gave birth in the last 12 months indicate that behavior change in Kamchewa was greatest in the area of utilization of ANC services, illustrated by more use of any ANC, more total visits during pregnancy, and first visits earlier in pregnancy, as compared to baseline. Similar increases were not observed in the control area, where these indicators remained relatively stable over the intervention period. The increase in use of health facilities for delivery reported by women in Kamchewa was large as well, but this result should be viewed with caution due to missing data on this indicator (see below). There is still much more room for improvement—at the final assessment less than half of women in the Kamchewa sample reported that they had given birth in a health facility. The increases in maternity service use reported by women in the survey are supported by the health facility service statistics. Although the needed improvements to the Kamchewa HC infrastructure could not be made during the study period, there are indications that the intervention had positive effects on the quality of maternity services. After the intervention training on interpersonal communication for health workers, the proportions of women reporting being treated “very well” by their ANC provider or birth attendant increased significantly in Kamchewa (from 13% at baseline to 61% at final assessment for the ANC provider, and from 32% to 52% for the birth attendant). Over the same time period, the proportions saying that they were treated “very well” by both of these types of providers actually decreased in Haboro. So, it appears that this training for health providers in the intervention area may have had beneficial effects. There were some significant challenges in the implementation of the community intervention in Kamchewa that may have limited its effectiveness. First, due to the fact that Kamchewa is very


distant from the NRSZ MOH Office in Massawa, regular supervision by that office was difficult due to lack of a vehicle and/or fuel, as well as lack of a clear mandate for this office to conduct this supervision. Thus, supervisory visits from the NRSZ MOH office were not conducted, outside of the special assessment visits conducted by the Central MOH and UNFPA. Second, the small improvements to Kamchewa HC requested by the community and local health workers were not able to be realized during the project period. This had a demoralizing effect on the community, the MHVs, and the local health workers. During the project period, it was never quite clear who should be responsible for these improvements and how the funds for it could be transferred from UNFPA, to the Central MOH, to the NRSZ MOH, to the Afabet Sub-Zone, and finally to Kamchewa. Third, upgrading of Afabet Hospital (the nearest hospital to Kamchewa) to be able to provide cesarean section services was not accomplished until the spring of 2007. The availability and accessibility of emergency obstetric care was seen as essential to the success of the project from the beginning, as it was realized that it would not do much good to make people aware of the need to use emergency obstetric care services if they were not actually available. Unfortunately cesarean section remained difficult to access for people in Kamchewa (nearest service around 3 hours away by Land Rover at Keren Hospital) during almost all of the intervention period. Fourth, there was some lack of clarity within the MOH regarding “ownership” of this project. The main responsibility for the project was initially given to the Health Promotion Unit, due to their expertise in community work and IEC, but the cooperation of other units—in particular the Reproductive Health Unit and Clinical Services—was necessary in order to upgrade the local maternity services and ensure adequate supervision. Lastly, delays in transfers of funds from UNFPA to the MOH to the local level negatively affected the intervention activities throughout the life of the pilot project, as refresher trainings and HF improvements could not be carried out at the time promised to the community. Also, some limitations of the evaluation research methods need to be recognized. The intervention area (Kamchewa) and the comparison area (Haboro) ended up not being as similar as had been assumed when they were originally selected in early 2005. Haboro has a larger population that apparently has had more access to information and educational activities than does Kamchewa. However, the fact that Kamchewa has reached the level of Haboro, and even surpassed Haboro on some key maternal health indicators, is impressive. In addition, having the intervention and control areas in different zones, made the conduct of the research operationally more difficult. Another limitation is the fact that there was a one-year delay between the baseline survey conducted in 2005 and the commencement of the intervention activities in March 2006, whereas it would have been best for the baseline data to have been collected in the period just prior to the intervention. On the other hand, it is a very impressive accomplishment that this complex intervention study (baseline data collection, intervention trainings and implementation, and follow-up data collection) could be completed successfully, largely through the efforts of the Health Promotion Unit, in 2.5 years. A further limitation was the lower sample size attained in Kamchewa at the time of the final assessment. The HPU team explained that they used the same methods (collaboration with community contacts in each village to identify all the households with women who had given birth in the past year) and visited the same villages as in the baseline survey. They do not believe that there is any systematic bias in terms of the women who could be found to interview, nor were any women avoiding participation. The drought conditions in that part of the country were mentioned as a possible cause of lower fertility. In addition, a wrong skip instruction in the questionnaire and subsequent missing data for 50 women on the labor and delivery questions meant that the survey results regarding skilled birth attendance must be viewed with caution.


Other limitations inherent in the study design included the fact that the sample of women who gave birth in the last 12 months necessarily does not include women who died during childbirth, who may have been lowest on the study indicators, and the fact that the survey data is based on self-reports—women may have given the answers they thought would please the interviewer. Despite the challenges and limitations, the evaluation results indicate that the community intervention was successful in increasing maternal health knowledge, attitudes, and practices in Kamchewa. It is impressive that this much change could be seen in a relatively short amount of time and it is possible that the effects will be even greater if the Maternal Health Volunteer intervention continues. It seems clear that the MHV intervention should continue to be supported in Kamchewa. In addition, similar strategies should be used in other parts of Eritrea, with some modifications and there is already a plan to implement a similar maternal health volunteer intervention in three sub-zones of Anseba with funding from Johnson & Johnson. RECOMMENDATIONS The following recommendations should be considered when adapting this strategy for other locations: It seems that such extensive and complex evaluation research (baseline and follow-up in

intervention and comparison areas) would not have to be repeated for new sites, but some simple evaluation should definitely be conducted. This could consist of the monthly monitoring forms used in Kamchewa and the 3-month supervision checklists, supplemented by review of health facility statistics and occasional rapid assessments of the impact of the intervention on community members (e.g., brief surveys, focus groups, in-depth interviews).

The cost of this strategy is quite low without the evaluation research (around $37,000 for initial and refresher trainings, plus around $2000 per year for regular supportive supervision). The main costs are for the initial and refresher trainings of the MHVs and health workers; including costs of transport for the training team from Asmara, per diems for the trainers and participants, and reproduction of training materials. Although it has been suggested that the strategy could be even more low cost if MHVs are not paid per diems for these trainings, given the poverty of the volunteers, this small incentive is greatly appreciated and is an additional source of motivation for them to do this work. It might be possible to provide foodstuffs instead of cash to the volunteers at the time of the trainings.

Regular 3-monthly supportive supervisory visits using a checklist would greatly enhance the effectiveness of this intervention. If this can be carried out by zonal or sub-zonal MOH staff located relatively near to the project community--and if it can be integrated into their regular supervisory duties—this should not be a large cost.

More emphasis on strengthening the role of male maternal health volunteers may have good results, since they appear to be the key decision makers regarding whether or not women use health facilities for ANC and delivery.

Although there may be benefit to integration of different community volunteer interventions in Eritrea, so that each village does not have multiple volunteers working on different topics, care should be taken not to overload unpaid volunteers with too many duties and topics. One good opportunity for integration may be the new neonatal home visit program.


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Documents

FINAL REPORT ON THE PILOT COMMUNITY MOBILIZATION ... · The purpose of this report is to present the findings of the evaluation of the Pilot Community Mobilization / Education Project