This document summarizes a project in Alamata, Ethiopia that aimed to increase facility births through embracing respectful maternity care. Key interventions included training midwives and nurses on respectful care, integrating traditional birth attendants into the healthcare system, increasing community awareness of birth risks, and improving the cleanliness and cultural sensitivity of the local health center. Over four years, these efforts led to a dramatic increase in facility births in Alamata, from only 20% previously to over 80%. The project demonstrates that respectful care can help overcome barriers preventing women from giving birth at healthcare facilities.

1. The effect of midwives
embracing respectful maternity
care on increasing facility births,
Alamata rural town district,
Northern Ethiopia
Dr Margaret Njenga – World Vision Kenya
3rd ICM Africa conference July 14 – 19th July
2013

2. Ethiopia: MNCH Health indicators
• Total Population = 82 million (2011 DHS)
• Under-five mortality rate (per 1000 live births) = 98 (2011 DHS)
• Neonatal deaths: % of all under-5 deaths = 34 (2010)
• Infant mortality rate (per 1000 live births) = 63 (DHS 2011)
• Stillbirth rate (per 1000 total births) = 26 (2010)
• Lifetime risk of maternal death (1 in N) = 67 (2010)
– ( in developed country = 1 in 3,800)
• Total fertility rate (per woman) = 4.8 (DHS 2011)
• Adolescent birth rate (per 1000 women) = 79 ( DHS 2011)
• Maternal Mortality Ratio (per 100,000 live births) = 676 ( DHS 2011)
• Contraceptive prevalence rate = 28.6% (DHS 2011)
Sources: DHS, MICS, MMEIG and other National Surveys

3. Skilled attendant rate

4. How World Vision Works
• Community based
• Do not provide health
services
• Aim to increase MNCH
knowledge & demand
for health services
• Aim for sustained
behavioural change
• Work in partnership
• Advocate for most
vulnerable child
• Fills the Gap
identified by local
health services & WV
• Working relationships
with HC staff, midwives,
TBAs & CHWs
• Together identify issues
and plan actions
• Agree on what WV will
fund & support

5. Project Area
• Alamata rural town is situated in Northern
Ethiopia, in the southern Tigray zone about
120kms south of the Mekelle, the capital of
the Tigray Region
• It is a peri urban context
• The HC serves a population
of 37,600

6. Why Respectful Maternity Care
RMC ?
• Recent studies have
highlighted abuse and
mistreatment of
pregnant and labouring
women
• Disrespectful treatment
is a clear barrier to
facility birth
• Childbearing women
have a right not to be
abused, hit, slapped,
exposed or abandoned

7. Midwives and Nurses need
support to provide RMC
In the same studies
Midwives & nurses
reported:
• Not being paid on time or
for overtime
• Not having adequate staff
for the workload
• No support from
management
• No support for involvement
with professional
association support
Promoting RMC -
Midwives and nurses
struggle to provide
RMC if they are not
respected and valued
www.popcouncil.org/projects/334_kenyaDigni
fiedBirthCare.asp

8. Background to project
(2009 – 2011)
• Identified as worst
performer for facility
delivery in the region
2005 – 2008
(80% birthed at home)
• Poor equipment, stock
out of supplies,
unhygienic
• Poor understandings of
how to change
behaviours
• High antenatal care
coverage BUT
• Low facility delivery
• Women came to facility
only if complications
• Preferred delivery with
TBA
• Shortage of staff
especially after hours
• Service charge

9. Commitment to change
• Alamata HC asked WV
for help
• Meetings held with
district administration,
women’s association,
community, pregnant
women & TBAs
• Identified solutions
• Agreed political
imperative for the
region and country
Agreed actions
• Create awareness of
benefits of facility
delivery
• Link TBAs to midwives
• HEW, WDA to track all
pregnant women
• Understand cultural
and other barriers to
facility delivery
• Incentives offered –
towel, soap

10. Community based interventions
• Located all TBAs in area
• Provided awareness
training on risk of home
delivery
• Integrated TBAs with
women’s association
and microfinance loan
for alternative income
• Provided TBAs with
opportunity to join the
WDA
• Encouraged TBAs to
accompany women in
labour
• HEW & WDA to track all
pregnant women
• Improved referral
processes including
communications for
labouring women to
contact ambulance

11. Political Will
• The Maternity Unit’s
promise to not let any
mother die
“No mother should die
giving life”
• Political leaders,
communities and
husbands also held
accountable for any
mother’s deaths at
home

12. Pregnant women’s feedback
• Don’t speak harshly
• Provide better privacy
• Fear of the unhygienic
delivery & facility (HIV)
• Eat and drink what they
want
• Allow coffee ceremony
before/after the birth
• Reduce/remove fees
• Provide transport
They valued TBAs but now
understood the difference
“ I didn’t know the
difference between a
TBA and a midwife
before this training. I
thought they were the
same”

13. Over life of project TBAs changed their
beliefs, attitudes & behaviours
• With awareness training
and support most TBAs
agreed to not deliver at
home & to promote
facility birth
• Most began an
alternative income
generation activity
“I felt guilty about what I
had done in the past”

14. Commitment at health facility
• Welcoming, respectful
atmosphere
• TBAs relationship with
women valued
• Non harmful customs
allowed ie: celebrations,
coffee ceremony,
praying, eating porridge
• Delivery room privacy
• Ambulance transport
for labouring women
• Investment in improved
quality (staff training
and equipment)
• Cleaner toilets and
delivery room
• Increased midwifery
and nurse staffing levels
= RMC

15. Respectful Maternity Care
Being allowed to:
• Eat porridge
• Pray
• Have a coffee
ceremony before/
after birth
“I feel at home”
A coffee ceremony is underway following the
birth of this mother’s second child. The first
was born at home. When asked how did she
feel after the birth of her baby she said “I feel
at home”

16. Results over 4 years (2009 – 2012)
• Staff were pleased but
surprised by rapid
change
• Many interventions
contributed - not just
RMC
• District now sharing
lessons learnt with 8
other districts

17. Alamata Town Health Centre
Champion lead midwife
Sr Sindayew

18. Conclusions
• Providing respectful maternity care can
contribute to an increase in access to
midwives and births in facilities
• Increased political commitment along with a
functional community health system are key
to meeting MDGs 4 & 5