ABSTRACT

This paper assesses the impact of the Adjibar Safe Motherhood Project and derives lessons of value to future interventions.

Amongst the participatory qualitative methods used were 15 group discussions, eight semi-structured interviews, a number of opportunistic informal

discussions and observation. The information gathering was complemented by a detailed review of project documents. Field visits for data collection took place over a six day period in March 2005.

The project was effective in raising awareness about maternal health, and the social, economic and health consequences of various harmful traditional practices (HTPs). It has also mobilised the community to monitor and report HTPs and has strengthened referral systems for counselling, support and treatment. A number of effective strategies were identified as having contributed to project success. These are presented using the framework offered by the Ottawa Charter for Health Promotion which presents five areas of public health action: developing personal skills; strengthening community action; building healthy public policy; re-orienting health services; and, creating supportive environments.

This evaluation contributes to and strengthens the expanding body of literature about effective development practices to reduce HTPs. It demonstrates that addressing HTPs takes time and long term investment; both are necessary to enable better understanding of the social and cultural reasons for HTPs before attempting to address them, and to build the community trust necessary to overcome the natural resistance to challenging such deeply entrenched practices. The project also highlighted the importance of developing a multi pronged strategy based on engagement with a broad range of stakeholders and supportive legislation.

Key Words

evaluation; female genital mutilation, harmful traditional practices; safe motherhood, Ethiopia

INTRODUCTION

All societies have some practices that are deeply rooted in tradition across generations and that reflect their values, culture and beliefs (Winter et al. 2002).While some of these practices may be beneficial, such as an emphasis on women's rest and good nutrition during the post partum month (Raven et al. 2007), others can be harmful (Office of the High Commissioner for Human Rights [OHCHR] 1995). Health professionals and international agencies have often varied in their attempts to conceptualise and address harmful traditional practices (HTPs) (Reproductive Health Outlook [RHO] 2004; United States Agency for International Development, 2006). Conceptualising HTPs as a public health problem and focusing on the associated health risks has influenced many responses, including awareness raising and legislation. However, the effect of education and legislation in isolation on behavior change has been limited. Those working to address HTPs are increasingly aware of the complexity of behavior change, the need to understand and respect social and cultural environments and to adopt responses that are both comprehensive and integrated.

In Ethiopia, a range of HTPs contribute to the poor health status of women. These include: female genital mutilation (FGM); early marriage; early pregnancy; practices which prevent women from controlling their own fertility; traditional birth practices; and nutritional taboos (World Vision Australia 2002).

The practice of FGM remains widespread in Ethiopia and varies across ethnic groups. In the Amhara region, which includes the project area, FGM is typically performed on the eighth day of life (Missailidis et al. 2003). The practice is often carried out by traditional practitioners, without anaesthetic and in unsterile conditions. The practice is traumatic and causes a range of short and long term complications that vary with the extent of the procedure (Shell-Duncan 2001). HIV transmission through FGM is theoretically plausible, especially in areas of high HIV prevalence typified by the project setting (Federal Ministry of Health 2004), where cutting instruments may be shared without adequate sterilization.

In accordance with international conventions (UN 1948; UN 1979; OHCHR 1989), the legal age of marriage in Ethiopia is 18 years. However, this is widely ignored and poorly enforced. Early marriage is particularly common in the Amhara region (Population Council 2004) and as a result many girls are denied the benefits of education which include improved health outcomes for themselves and their children, reduced fertility and improved economic status (Mathur et al. 2003). For many girls, early marriage also means an abrupt transition to sexual relations with a husband who is considerably older (Population Council 2004; Erulkar et al. 2004).

A positive association between early marriage, a large marital age gap and infection with HIV has been established in some parts of Sub-Saharan Africa (Glynn et al. 2001) Furthermore, the risk of HIV infection increases for girls who have been married and subsequently become widowed, divorced or abandoned (Bruce 2005). It is suggested that up to 12% of previously married girls in the Amhara region are already divorced or widowed (Erulkar et al. 2004).

For most girls in rural Amhara early marriage is followed by early pregnancy (Erulkar et al. 2004). Adolescent pregnancies typically result in worse outcomes for both the mother and baby, when compared to pregnancies occurring in physically mature women (Kumbi & Isehak 1999; WHO 2001).

Ethiopian families have traditionally given low priority to antenatal, delivery and postnatal care, and to avoidance of heavy work and ensuring good nutrition during pregnancy. Most women give birth at home and few babies are delivered in the presence of a skilled attendant (Federal Democratic Republic of Ethiopia Central Statistics Office 1999). Women and girls have had little control over their fertility because of lack of access to services, lack of awareness, illiteracy, and severe gender inequalities. Fertility rates are high and only 6% of married women report to using a modern form of contraception (Central Statistical Agency 2005).

Various initiatives have been put in place to address HTPs in the most affected regions of Ethiopia and one such initiative was the Adjibar Safe Motherhood Project. The effectiveness of such initiatives is rarely documented, and so the purpose of this paper is to describe the approach taken in this instance, and to discuss impact and derive lessons which could be generalized to other similar projects and settings.

Adjibar Safe Motherhood Project

The Adjibar Safe Motherhood Project was a six year World Vision Australia project funded by the Australian government aid agency, AusAID (World Vision Australia 2002). In response to the community's concern about high rates of maternal deaths and morbidity, the project's focus was maternal health, with the aim to benefit the district's 38,860 women of childbearing age. Strategies included strengthening facility and community level health services, improving referral capacity and increasing access to emergency obstetric care and essential drugs. Attention was also given to HTPs such as FGM, abduction and marriage of young girls, early sexual relations and pregnancy, traditional birth practices and practices that have prevented women from controlling their fertility. These were identified as contributing to the high rates of maternal mortality and morbidity in Adjibar and surrounding areas.

EVALUATION METHODS

Project site

Adjibar, the project site, is a small township in the remote Ethiopian highlands. Located in the Tenta Woreda district of the Amhara region, it is 522 km north east of the capital, Addis Ababa. The nearest referral centre capable of delivering emergency obstetric care is in Dessie, the zonal capital, which is 122 km from Adjibar and three hours by unsealed road.

Consistent with best practice in community development (Israel et al. 1998), an evaluation team was formed from members of the project staff and the Woreda Council and facilitation was provided by an external consultant. The team collected data for a week in March 2005 using a variety of methods including review of relevant project documents, fifteen group discussions, eight semi-structured interviews, and a number of opportunistic, informal discussions.

Sample

We used purposeful sampling to enable consultation with representatives of all groups involved with or affected by the project. We aimed to achieve a gender balance in our consultations, and to meet with community members of different ages and from different cultural groups. Group discussions (with 8-12 participants) were held with: trained traditional birth attendants (TBAs); community-based reproductive health workers (CBRHWs); pregnant women; women who had delivered a baby within the past two years; women who had undergone fistula repair surgery now working as community advocates; male and female elders/ leaders; members of the Tenta Woreda Council; and, male and female elementary and secondary school students. The team also interviewed teachers and health workers. All those who participated did so voluntarily, providing free and informed consent. The field work was approved by relevant government authorities (Tenta Woreda Council) in Adjibar and by the national World Vision offices in Australia and Ethiopia, and this served as the process for ethical review.

Method

Focus group discussions and key informant interviews were the main methods of information gathering. Qualitative methods such as these are appropriate when attempting to explore the meaning of events and behaviours rather than count them (Hudelson 1996). The local project team and the facilitator collaborated to develop question guides. Questions were translated from English into Amharic by one group of local staff and then independently reviewed by another group before discussion by the whole group to verify accuracy of translation. The group discussions and interviews covered a range of topics relevant to the broader project, as well as to the aim of reducing HTPs. The questions about HTPs explored knowledge, attitudes and practice in relation to FGM, early marriage, early pregnancy, pregnancy and delivery care, and family planning. The 'formal' information gathering process was complemented by observation, informal discussions and a thorough review of project documents.

Data analysis

A designated note-taker documented the group discussions and interviews. All notes were discussed and reviewed at the end of each day by the evaluation facilitator, together with the discussion group/interview moderators and note-takers. Notes were altered as necessary to reflect corrections of minor additions that resulted from the discussion. The group review and discussion of the notes was invaluable to ensure accuracy of interpretation.

We undertook a thematic analysis of the notes to identify recurrent themes and similarities and differences across the various groups of participants. This approach to analyzing qualitative data is deemed appropriate in the literature (Pope et al. 2000). Findings were integrated with the findings from the review of project documents and field trip observations.

RESULTS

The Adjibar Safe Motherhood Project was effective in raising awareness about maternal health, and the social, economic and health consequences of various HTPs. It has also mobilised the community to monitor and report HTPs and strengthened referral systems for counselling, support and treatment. A number of effective strategies can be identified as having contributed to project success and are presented using the framework offered by the Ottawa Charter for Health Promotion (WHO 1986), which presents five areas of public health action: developing personal skills; strengthening community action; building healthy public policy; re-orienting health services; and, creating supportive environments.

Developing personal skills

A range of 'influential' community representatives were equipped with the knowledge and skills to educate the community on the consequences of HTPs and to stimulate discussion. These people were recognized within the community as having some kind of recognized 'status' and ability to influence others. Influential groups included Traditional Birth Attendants (TBAs), Community Based Reproductive Health Workers (CBRHWs), teachers, and women who had undergone fistula repair surgery. These groups were also involved in raising awareness of community and facility-based maternal health and family planning services that had been strengthened through another component of the project.

Discussions provided evidence of changes in understanding and attitudes towards many HTPs. For example, people of all age groups (primary and secondary school age children, adults of reproductive age and elders) had a very thorough understanding of issues related to FGM, mentioning the immediate risk of 'blood loss', and the later life complications of 'scarring' such as loss of elasticity of perineal tissues, delayed labor, tearing, hemorrhage, fistula, reduced sexual satisfaction and the likelihood of 'painful sex'. Understanding of the risk of serious infection, including HIV and tetanus from dirty or shared blades, was also evident, with one elementary school boy stating: 'In the past ... even two to three infants were circumcised using the same blade.'

Attitudes have shifted from acceptance to disapproval. One mother commented that 'It should not even be done in a clinic' and others nodded in agreement. Those working to reduce HTPs reported that parents and grandparents no longer challenge them when they teach about FGM. Health workers and mothers of young children reported that FGM is not happening at all these days.

Strengthening community action

The project effectively developed community capacity and commitment to monitoring and reporting the occurrence of HTPs such as early marriage and FGM. Community members were encouraged to report the occurrence of such practices to teachers, health workers or the local Woreda Council, who would refer matters to law enforcement authorities. Important lessons have been learnt in relation to building such a strong community response to early marriage, of note, processes around verification of age. The Woreda Council note that early in the project families were sending an older sister (of the girl proposed for marriage) to the health office for verification of age; as a consequence photo identification is now being used as part of this process.

The project also worked to improve community attitudes toward birth spacing and caring for pregnant and delivering women. For example, by promoting preparedness for the event of delivery complications and by encouraging people to openly discuss the benefits of family planning.

A Woreda Council member commented on the improved community commitment to safer delivery care: 'Pregnant women are encouraged to have a transport plan in case of emergency--people used to make a traditional stretcher after complications happened--but now they have one in reserve in case anything goes wrong.' In relation to birth spacing, the project has seen widespread attitude change and improved rates of contraceptive uptake. One TBA reported: 'In the past there were mothers with as many as twelve babies but nowadays they have a maximum of three.' Much of this success can be attributed to the use of CBRHWs who provide basic family planning services with referral to health institutions as appropriate. Most of these workers are male; a deliberate response by the project based on understanding of gender inequalities and the traditional role that men have played in determining family size.

The project approach has been to 'teach the males first' and then counsel couples together. Several mothers of young children spoke in agreement about their husbands changed attitudes: 'Now we hear about modern methods they don't push us to have many children ... they even encourage us to use contraceptives and remind us if we have taken the pill.' CBRHWs have been very effective in developing strategies to change wide held opinions and overcome any concerns about potential side effects from some contraceptive methods. They say that they use themselves or their relatives as examples; an effective argument, as community members would not expect them to cause harm to themselves or their relatives. There is also a tendency to promote the financial and family health benefits of family planning to those they educate: 'It used to be commonly felt that a child is a gift from God and we should have them whenever we can and that he may earn money for us in the future. But we tell people ... look around and see what happens in homes where there are so many children and look at homes that use family planning' (CBRHW). This argument seems to appeal to the men especially.

With the hope of achieving sustained commitment to family planning, school children have also been the target of such education. It was our observation that they demonstrated a high level of knowledge about contraceptive options and the benefits of family planning, both financially and in relation to maternal health. One elementary school boy effectively described family planning as 'having the right number of children with proper spacing and according to ones [financial] ability'.

Building healthy public policy

In addition to encouraging the community to monitor and report HTP's, the project has worked with authorities to ensure that previously ignored legislation is enforced. Enacting legislation has been a strong deterrent and the occurrence of FGM and early marriage is noticeably declining. In relation to FGM, one TBA said: 'Nowadays people don't even mention it, let alone do it ... the circumcisers won't practice for fear of legal back up.' As for early marriage, the Woreda Council reported that in the past young girls were being married as young as nine years. Now, as a result of collaboration between sectors including education, health and law enforcement (together with community groups) this is a steeply declining trend and a rare occurrence.

In the year preceding the evaluation, teachers reported that 320 cases of proposed early marriage were reviewed by legal authorities. Of these, 76 marriages were permitted on the grounds of appropriate age (18 years or older) and many of these young girls have also been able to continue with their schooling; the remaining 244 were counseled and of these only four families continued to challenge this finding. Importantly, there seems to be a stronger awareness of individual rights. This is reflected by one elementary school girl's definition of early marriage as being 'when we are made to marry someone we don't want without our will'.

Re-orienting health services

Health workers were encouraged to broaden their clinical practice and take a more holistic approach to care. For example, this might include being alert to verbalisations of early marriage or FGM, counseling families against the practices and reporting any likely cases. Health workers were also encouraged to see clinical encounters as an opportunity for health education, and for example, to educate women attending for ante natal care on the importance of good nutrition (especially protein consumption, which is commonly avoided), the benefits of attended delivery and the importance of an emergency transport plan. Finally, there was a greater emphasis on health workers improving their links with community level workers such as TBAs. Together these changes have resulted in a strengthened system of delivery care, as explained by the mother of one young baby:

   Years back the system was bad, there was no
   delivery system. Now, we have the TBAs to
   help us, they give us a safe and clean delivery.
   There are less frequent pregnancies because
   of family planning. If you compare the old
   system with the new system it's like the 'sky
   and the earth'.

Creating supportive environments

Males and females of all age groups were targets of awareness raising and efforts to promote dialogue and bridge the communication gap that exists between young people and adults. This contributed to creating a supportive environment for attitude and behavior change across the broader community. A wide range of influential community groups were engaged from the very beginning and developed a genuine commitment to working together to reduce HTPs. Anti-HTP Clubs were established in schools, educating on the issues and connecting students with a trusted teacher who would advocate on their behalf if necessary. For example, teachers will make home visits to investigate a girl's dropping out of school, and if necessary, initiate a series of actions to notify health, law enforcement and other community officials of a proposed early marriage.

DISCUSSION

The findings suggest that the project was instrumental in helping people in Adjibar to overcome culturally ingrained harmful practices. It is noteworthy that the strategies adopted to address HTPs were based on an early commitment to gathering information to better understand the various cultural beliefs and practices before attempting to change them.

Findings suggest that one of the project's major achievements include increasing family planning coverage and routine care of pregnant women. This can largely be attributed to the deliberate involvement of male community workers, an effective strategy that has been previously reflected in the literature (Population Council 2002). The need to involve men in order to improve the health and health seeking behaviour of their wives was clearly demonstrated. However, overall success of this outcome is potentially hampered by some remaining behaviour change and gender related issues. There continues to be a heavy reliance on female family planning methods and reluctance among some men to use condoms. This has strong relevance for HIV prevention, especially at this stage of the epidemic in rural Ethiopia when incidence is high. Furthermore, despite the high level of awareness of the risk of HIV/ STI transmission from unprotected sexual activity anecdotal findings suggest no linking of HIV risk with early marriage and the fact that this usually involves an older, more sexually experienced husband. Recommending condom use within marriage is often a neglected HIV intervention and is something that should be considered in family planning initiatives.

The issue of early marriage remains commonplace in both rural and urban Ethiopia and cultural beliefs and socio-economic pursuits are commonly cited to justify the practice. While these factors have been challenged and to a large extent overcome in the project area, some parents continue to be concerned about seeing their children (especially girls) coupled before they die. Continued efforts to overcome this practice may require deeper understanding of the social and cultural reasons that underpin early marriage, as well as a persistent approach to enforcing the legal framework.

With some 73% of Ethiopian women estimated to have undergone FGM, couching the practice as a human rights issue has often been perceived as unnecessary 'outside' interference and a form of cultural imperialism (Alfara 2002). In an effort to address this deeply entrenched and sensitive issue, the project used a cultural competence framework. In this sense, cultural competence is much more than awareness of cultural differences; it encompasses a set of congruent behaviors, attitudes, and policies that come together in a system, agency, or among professionals and enables that system, agency, or those professionals to work effectively in cross-cultural situations (Cross et al. 1989; Renzaho 2008,Waters et al. 2008). To become more culturally competent, a system needs to: value diversity; have the capacity for cultural self-assessment; be conscious of the dynamics that occur when cultures interact; institutionalise cultural knowledge; and adapt service delivery so that it reflects an understanding of the diversity between and within cultures (American College of Obstetricians and Gynecologists [ACOG] 1998; Royal Australasian College Physicians [RACP] 1994). The fact that the project started with identifying cultural differences and strengthened the response through integration of this cultural understanding, made the project culturally competent. In this case, the project raised awareness about FGM and the adverse health consequences and encouraged dialogue about the common myths underpinning the practice. Support was mobilized from a range of stakeholders including health professionals, TBAs and advocates who have resisted and spoken out against HTPs. In doing so, the project demonstrated that it is possible to change culturally entrenched beliefs and practices, through interacting and helping people to understand risks and possible alternatives.

Other lessons from the project reinforce the importance of working with males and females of all age groups and to promote community and intergenerational dialogue (Abdel-Tawab & Hegazi 2000; von Roenne 2005) in order to create a supportive environment for change. As documented elsewhere (Abdel-Tawab & Hegazi 2000; von Roenne 2005), community engagement and efforts to encourage social responsibility were important, as was an acknowledgement of the need for long term investment to achieve sustainable results. Also critically important and often so difficult to guarantee, was the presence of a project manager who remained with the project throughout the six years. The character and personal qualities of this individual enabled him to achieve a high level of trust and respect and allowed for a true working partnership to evolve between the NGO, the community and other stakeholders.

Limitations

The evaluation findings are limited to some extent by our approach to sampling and data collection. Community members who participated in the evaluation were not strictly representative of all project beneficiaries, because we were unable to include representatives from very remote areas. The qualitative approach to data collection with a reliance on group discussions and interviews may have biased our findings; it is possible that some participants may not have expressed their own views, but rather opinions that they thought would be most acceptable to the interviewers or others in the group discussion. Despite these limitations, we feel that the information gathered provides valuable insights for development workers, donors, policy makers and local governments similarly engaged in seeking to address HTPs.

CONCLUSION

This evaluation contributes to and strengthens the expanding body of literature about effective development practices to reduce HTPs. It demonstrates that addressing HTPs takes time and long term investment; both are necessary to enable better understanding of the social and cultural reasons for HTPs before attempting to address them, and to build the community trust necessary to overcome the natural resistance to challenging such deeply entrenched practices. The project also highlighted the importance of developing a multi pronged strategy based on engagement with a broad range of stakeholders and supportive legislation.

Acknowledgements

We would like to acknowledge the World Vision Ethiopia project team, especially Yenealem Tafere, for their enthusiastic participation during the Adjibar Safe Motherhood Project end evaluation. We would also like to thank Dr Wendy Holmes for her technical advice prior to the evaluation, and for her generous guidance in the preparation of this paper.

Received 24 October 2007

Accepted 22 May 2008

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LISA NATOLI

Women and Children's Health Advisor Centre for International Health

Macfarlane Burnet Institute for Medical Research and Public Health

Melbourne VIC, Australia

ANDRE MN RENZAHO

Senior Research Fellow

School of Health and Social Development

Deakin University

Burwood VIC, Australia

TONY RINAUDO

Senior Country Program Coordinator

Africa, Middle East and Eastern Europe Team

World Vision Australia

East Burwood VIC, Australia