Hospital deliveries in Afambo: a success story

Abdella Isse, Monitoring & Evaluation Coordinator for the Afar Pastoralist Development Association, sat down with mother of six, Kulsuma Ahmed, to talk about her experiences of giving birth in Afambo in the Afar region of Ethiopia.

Kulsuma Ahmed is a mother of six from Afambo in the Afar region of Ethiopia. Image: Abdella Isse / APDA

Kulsuma Ahmed is a mother of six from Afambo in the Afar region of Ethiopia. Image: Abdella Isse / APDA

Many pastoralist women such as Kulsuma Ahmed, pictured above, from Afambo in the Afar region of Ethiopia, give birth at home. It is the cultural norm within the nomadic Afar community, despite not being the safest delivery setting for mothers and their newborns.

In the portable dome-shaped huts in which nomadic families live and women give birth, sanitation and hygiene are constant issues, water is not always readily available, and mothers are a long way from skilled medical support if they run into complications. Communities often live 30-40 kilometres from the nearest road.

Traditional birth attendants (TBAs) usually assist women during pregnancy and childbirth due to challenges of distance and lack of health facilities. The percentage of deliveries assisted by qualified health personnel in the Afar region is just 6.2 percent – compared to the national average of 18.4 percent.1

The Afar Pastoralist Development Association (APDA), Anglican Overseas Aid’s partner in The Road Less Travelled project, has been working with pastoralist women to educate the community about the benefits of attending a health facility at the time of birth. This education is delivered to the pastoralist women through the organisation’s Women’s Extension Workers and Health Extension Workers.

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Mobilising communities in the fight for safe motherhood

Momina sits on the bed in the hut where she will give birth to her third child. The bed is a traditional Afar “oloiyta” made of thatched sticks and slightly raised. She is ready to deliver any day now.

“The baby has been moving around a lot,” Momina says. She is nine months pregnant, and is visited twice a week by a Women’s Extension Worker (WEW) from the Afar Pastoralist Development Association (APDA) – the Ethiopian partner of Anglican Overseas Aid in The Road Less Travelled project.

Momina is nine months pregnant and waiting to give birth at home, with the support of a trained traditional birth attendant. Image: Kate Holt / Anglican Overseas Aid

Expectant mother, Momina, is waiting to give birth at home in the remote Afar region of Ethiopia.
Image: Kate Holt / Anglican Overseas Aid

The WEW has monitored Momina throughout her pregnancy, and provided antenatal care. However, this has not always been the case for women giving birth in the Afar region of Ethiopia. In one district surveyed by the project, 66 percent of women reported having received no antenatal care during their most recent pregnancy. (Read more in our Baseline Report).

As a country, Ethiopia has one of the highest ratios of maternal mortality in the world, in 2011 recording 676 maternal deaths for every 100,000 live births.1 For women in the Afar, the risks of injury or death during childbirth are even greater.

Due the remoteness of the Afar pastoralist communities and their nomadic lifestyle, communication, transport and access to health services has in the past been extremely limited or non-existent. There are also significant cultural or attitudinal factors that affect the care mothers receive during pregnancy, delivery and post-delivery.

APDA is improving the chance at life for Afar mothers and their children, by mobilising members of the community in the fight for safe motherhood. With a 20-year history working within the pastoralist setting, the organisation is uniquely positioned to facilitate relief and development activities that are relevant to the community, and implemented by the community.

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The Afar tradition of disability inclusiveness

Teacher Humaid Said shared his experiences of disability inclusiveness in the Afar community of Ethiopia with Tanya Caulfield of the Nossal Institute for Global Health – Anglican Overseas Aid’s partner in The Road Less Travelled project.

When he was 12, Humaid Said contracted polio and lost the use of his leg.

In many developing countries, Humaid would have been consigned to a life on the margins of his community. People with disabilities are among the poorest and most vulnerable and are often at greater risk of social exclusion.1 This, in turn, reduces their access to education and healthcare, along with opportunities to participate in decision-making and provide for themselves and their families.

But for Humaid, growing up in the rural Afar region of Ethiopia was an entirely different experience that challenges the notion that development work must always teach people about how to include people with disabilities.

The nomadic pastoralists of the Afar have a deeply embedded traditional social support network, and the concept of excluding an individual from family and community life based on their disability is perceived to be counter to Afar cultural laws.

Teacher Humaid says that in Afar culture, people with disabilities are active participants in the community.  Image: Tanya Caulfield / Nossal

Teacher Humaid says that in Afar culture, the community perception is that no one should be treated differently.
Image: Loretta Pilla

“When I was younger, I would see others participating in activities when I couldn’t, so I wished to be like them,” he explained. “But the community perception is that no one should be treated differently – there is a law in Afar tradition not to treat people differently in the family and the clan.”

Despite wishing at times that he had full use of both legs, Humaid said that in Afar culture people with disabilities are active participants in the community and are involved in different ways in socioeconomic activities.

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From Australia to Afar, all mums matter

This month, The Road Less Travelled was honored to have our partner, Valerie Browning, in Australia to share firsthand the realities, challenges and innovative approaches the project has adopted to improve maternal health in the remote Afar region of Ethiopia.

Read our article on the Mamamia blog or listen to the radio interview with Valerie on 3ZZZ.

While she was in Australia, Valerie connected with health professionals, educators, students, researchers, and members of the general public, to talk about what life is like for the nomadic pastoralists she works with.

Many of the audience left feeling inspired by Valerie’s determination to do whatever she could to help the Afar in developing locally-appropriate solutions to the immense development challenges they face.

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Stories from Afar with Valerie Browning

Inspirational Aussie nurse, Valerie Browning, is currently in Australia to share stories of her work in maternal and child health with the nomadic pastoralist Afar communities of Ethiopia.

Valerie’s organisation, the Afar Pastoralist Development Association (APDA), is a partner in The Road Less Travelled, a project of Anglican Overseas Aid that is supported by AusAID.

Valerie will be speaking at the Nossal Institute for Global Health at the University of Melbourne next Wednesday 14 August, a special event of the Nossal Seminar Series.

Inspirational Aussie nurse, Valerie Browning (centre), is in Australia to share her experiences working with the nomadic Afar communities of Ethiopia to improve maternal and child health.

Inspirational Aussie nurse, Valerie Browning (centre), is in Australia to share her experiences working with the nomadic Afar communities of Ethiopia to improve maternal and child health.

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Report from Afar calls for focus on access and appropriateness of maternal health services

A baseline report released this month by The Road Less Travelled (TRLT) project supports the theory that improved maternal and child health outcomes cannot be achieved through health interventions alone. The project, led by Anglican Overseas Aid (AOA), has adopted a holistic, strengths-based approach to its community development activities, which includes measures to address education and literacy as well as to improve access to water, food security, and livelihoods.

This report presents the findings from a Baseline Assessment undertaken in late 2011 among nomadic pastoralist communities in the Sifra and Yallo woredas (districts) of the Afar region of Ethiopia. The research was carried out by TRLT project partners the Afar Pastoralist Development Association (APDA) and the Nossal Institute for Global Health. It builds on the project participatory design process which identified community assets, important cultural and gender issues impacting on health, and challenges in accessing basic services.

Maternal and child health baseline survey among nomadic pastoralist communities in the Afar region of Ethiopia.
Image: Christof Krackhardt / APDA

A quantitative questionnaire was administered to 400 pastoralist households – 200 from Sifra and 200 from Yallo. The questionnaire was administered to a man and a woman from each of the participating households. Qualitative data was captured via a series of focus group discussions based on semi-structured question guides and through Community Resource Mapping and community forums which identified resources and services available to the communities.

In her Foreword to the report, APDA Project Coordinator Valerie Browning explains:

“The report cries out that access and appropriateness of services and resources, specifically health and water, must receive due attention in order to enable safe motherhood.”

The baseline data allows for a deeper understanding of the knowledge, attitudes and practices regarding maternal and child health and other issues impacting on health in Afar communities.

“Since all issues raised in the report are well within the realms of APDA’s experience and expertise to tackle, this Baseline Report should energise the project team on to greater alliance with the community in the facilitation of the planned safe motherhood initiatives in each of these project districts, while providing a contextual pattern for the remaining project districts.”

If you’re interested in learning more, you can download the full report here.

The Road Less Travelled is a project of Anglican Overseas Aid, and is being delivered with the support of AusAID.

Video: Eliminating barriers to skilled birth attendance

Following on from our previous post, here is the second clip featuring our team in action at the Global Maternal Health Conference (GMHC) last month. Valerie Browning of the Afar Pastoralist Development Association (APDA), our Ethiopian partner, led a panel discussion around a topic very close to her heart, “Eliminating barriers to skilled birth attendance.”

This two-part video from the Maternal Health Task Force gives insight into some of the incredible work being done and different strategies being adopted in Ethiopia, Burkina Faso, India and Bangladesh, in an effort to improve skilled birth attendance. (You can view Valerie’s presentation on APDA’s work from the beginning of the second video).

Eliminating barriers 1 from Maternal Health Task Force on Vimeo.

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Improved safety for Afar pastoralist mothers

In the Afar region of Ethiopia, 93 percent of mothers deliver their babies at home with the assistance of traditional birthing attendants (TBAs). Safe motherhood is fundamental to overall community development, and the Afar Pastoralist Development Association (APDA) is addressing the needs of the community through a holistic approach.

This includes a focus on strategies to increase access to water, since females traditionally collect water; improve the health of livestock, so that milk is readily available; improve household economies through income generation activities; and enhance access to education and literacy.

APDA’s programs aim to lessen the workload of females in daily household chores, stop harmful traditional practices that have a negative effect on women’s health and wellbeing, and to facilitate Afar women to be implementers of development change within their society.

The struggle for safe motherhood ideally takes place within the pastoralist home, led by the community and managed by the local government, including the traditional leadership.

Literate pastoralist women trained in safe motherhood work alongside APDA-trained traditional birth attendants in the remote Afar region of Ethiopia.
Image: APDA / Christof Krackhardt

Having selected the most active and popular TBAs in the community, APDA has trained 1,036 TBAs on basic hygiene, sanitation, clean delivery, antenatal care, and recognition of risk pregnancies. Trained TBAs are equipped with clean birthing kits for each delivery. This has resulted in the establishment of clean birthing processes and a referral mechanism to health institutions for ‘risk’ pregnancies.

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Representing marginalised communities at a global level

The Road Less Travelled project partners will take to the stage at the Global Maternal Health Conference next month, to represent the nomadic pastoralist communities the project works with in Ethiopia and Kenya.

The conference, which is being held in Tanzania from 15-17 January 2013, brings together scientists, researchers, and policy-makers from all over the world to network, share knowledge, and build on progress toward eradicating preventable maternal mortality and morbidity by improving the quality of care.

Valerie Browning, Australian midwife and founder of the Afar Pastoralist Development Association (APDA), will be part of a panel presenting strategies to eliminate barriers to skilled birth attendance.

Valerie Browning (right) will be a panellist at the Global Maternal Health Conference in January 2013, presenting the Afar Pastoralist Development Association’s strategy for safe motherhood to a global audience.
Image: Anglican Overseas Aid

Recognising the important role of Traditional Birth Attendants (TBAs) in maternal and child health development in pastoralist communities, APDA is working with TBAs, communities, and local governments to reduce maternal and newborn mortality in Afar region of Ethiopia. Valerie will share APDA’s community-level strategy for safe motherhood in her presentation titled “Trained traditional birth attendants: Today’s missed opportunity”.

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The great challenge in pastoralist children’s education

Educational opportunities for girls in Ethiopia’s remote Afar region are limited beyond primary school, due to some community resistance against educating girls.
Image: Christof Krackhardt

For the nomadic pastoralist communities of the Afar region in Ethiopia, education is a major challenge. Anglican Overseas Aid’s project partner, the Afar Pastoralist Development Association (APDA), began its literacy program back in 1996 with the initial training of 21 teachers. Since then, the program has grown significantly. There are currently 231 teacher-sites in 14 of the region’s 29 woredas (districts).

During this time, APDA’s program strategy has evolved to improve coverage and quality of education, assisting the regional government to devise policies and to implement appropriate education options in the pastoralist setting. While primary level education is being achieved in many nomadic pastoralist communities through a combination of mobile and static education, the question now is how these children will continue on.

APDA is piloting a strategy that will ensure more children in the isolated Afar region gain access to education on an ongoing basis. Students who would otherwise not have the opportunity to continue schooling, move to a town to live in student hostel accommodation. They are supported to live while they attend the local government school from grade five onwards.

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