Saving the lives of women and children through access to health services

Abdella Issa, Monitoring & Evaluation Officer with the Afar Pastoralist Development Association (APDA), was interviewed by Ernest Etti from the AACES Resource Facility, about the changes he has noticed in the pastoralist communities of Ethiopia since he became involved in the AACES program, through The Road Less Travelled project.

Can you tell me about when and how you became involved in the AACES program?

I joined the AACES program in August 2011 and this was during the orientation of staff and government in the seven target districts in Ethiopia. I was recruited as a Monitoring and Evaluation Officer, and was briefed about my roles at that time.

What do you think are some of the changes you have experienced since you have been involved in the AACES program, thinking in particular about AACES partnerships and about civil society?

There are indeed changes in maternal and child health in the seven districts. There are changes on the ground like improvement of mothers delivering at hospitals. Malnutrition among children has also decreased and there are changes at a district level as well, like the establishment of stakeholder committees, which meet every six months to review progress of the project and discuss improvements of services on the ground.

There are also annual reflection meetings at a district level, to review progress of work for the past twelve months and then agree on plans for the next twelve months. These meetings have also improved relations among stakeholders; district local government, community leaders and other NGOs working in the same districts.

The project also conducted research at a regional level to investigate the role of women extension workers at community level. The key finding was that women extension workers are central to reaching out to pregnant women in pastoralist communities. Previously, there were more male extension workers, a situation that hindered access to health services on the part of pregnant women in pastoralist communities. Research results were shared with district and regional officials and it is expected that government will in future start recruiting more women extension workers in the field of maternal and child health.

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If these hands could talk

I remember gazing at the hands of a traditional birth attendant in pastoralist Laikipia, Kenya, and wondering about the stories they might hold. How many newborns had these hands supported into the world? What challenges had been faced by the women they helped through childbirth, in their remote rural homes far from any health clinic? Beneath the rough and wrinkled surface, how much loss had they absorbed through these experiences?

The hands of a traditional birth attendant in Laikipia County, Kenya.  Image: Hannah Ford / AVI

The hands of a traditional birth attendant in Laikipia County, Kenya. Image: Hannah Ford / AVI

Sub-Saharan Africa has the highest maternal mortality rate, bearing the burden of more than 50 per cent of the world’s maternal deaths. One in 39 women in this region faces the risk of dying in childbirth in their lifetime.

Yet less than half of all mothers in sub-Saharan Africa have the support of a trained midwife, nurse or doctor during childbirth. Even fewer mothers from the marginalised nomadic pastoralist communities of Kenya and Ethiopia have access to skilled birth attendants. While evidence has shown that access to skilled care during pregnancy, birth and post-delivery, is key to saving lives, many women don’t have an option.

For the past two years, I’ve had the privilege of working on The Road Less Travelled project and coordinating this blog. I have learnt so much during this time. As I reflect on my experiences, what stands out to me most is the strength and resilience of the pastoralist communities at the heart of the project – and especially that of the mothers. They want what all women want for their children: the chance to survive and thrive.

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Let our sisters learn

For pastoralist children in the isolated Afar region of Ethiopia, access to education has always been extremely limited. For girls, there is even less opportunity. The Afar Pastoralist Development Association (APDA), which began its first literacy program in 1996, is responding to the situation.

Since APDA started the literacy program, it has evolved to improve the coverage and quality of education in the Afar region, with an emphasis on education options that are appropriate for pastoralist children. While primary level education was being achieved in many areas through a combination of mobile and static education, the next challenge was to come up with a solution for how the children would continue their learning.

As an extension of the literacy program, APDA has been piloting a strategy that will ensure more girls gain access to education on an ongoing basis.

In the first year it was difficult to get girls into the student hostel, but over time pastoralist families have come to realise the benefits of giving their daughters the opportunity to learn. Image: Kate Holt / Anglican Overseas Aid

The Road Less Travelled project partner APDA is working with remote pastoralist communities in the Afar Region of Ethiopia to increase girls participation in education.
Image: Kate Holt / Anglican Overseas Aid

Through The Road Less Travelled, a partnership project led by Anglican Overseas Aid, APDA has established a student hostel in the town of Asayita. Pastoralist children from remote rural areas move to the town to live in the student hostel accommodation during the school term, so they have the opportunity to continue learning. The project supports the students to live while they attend the local government school from grade five onwards.

A key priority of the hostel is to increase girls’ participation in education – a challenge that has been met with some resistance from pastoralist communities. One factor that has helped to pave the way for Afar girls is the presence of the hostel house mother, Lako.

Lako is a mother from the same remote community as the students, and responded to APDA’s search for a volunteer house mother.

“They needed someone, so I said I’d go,” she says. “The best thing I can do is look after children. If our children learn, we can have a great future.”

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Improving the use of maternal, neonatal and child health services in rural and pastoralist Ethiopia

This guest post is written by Dr Ruth Jackson of the Alfred Deakin Research Institute. Dr Jackson is working on a project focused on improving the use of maternal, neonatal and child health services in rural and pastoralist Ethiopia. The project is funded by the Australian Development Research Awards Scheme. Dr Jackson has been learning from the experiences of Women’s Extension Workers who work with the Afar Pastoralist Development Association, a partner in The Road Less Travelled project.

“You won’t believe us – we start walking in the morning up til night time to collect water. Then we grind the wheat, collect sticks for firewood and take water to the animals. Sometimes if we have to sleep where we collect water, we take our baby with us, otherwise we leave the baby in the house.”

– Women’s Extension Worker, Logya, Afar Region, Ethiopia, 25 March 2014

We are sitting in the shade at the Afar Pastoralist Development Association (APDA) training facility with 19 Women’s Extension Workers. The women, many with young children and babies, are attending their annual refresher training. It’s too hot to sit inside the training centre but relatively cool in the shade of the building.

Along the fence line are the rooms in which the women stay for the month. Although they are square and joined together they are built of the same materials as the Afar huts or aris. Aris are normally hemispherical and made of palm ribs covered with matting. They are light and portable and easily dismantled – a job usually done by women.

While the Women’s Extension Workers are away from home attending training their husband or mother has to collect water. Men don’t like collecting water as it’s “women’s work”. But one Women’s Extension Worker explained that they had to help their husbands understand that “helping each other is good. Some men joke about doing it while others don’t like doing it … in the past, some men even refused to allow their wives to come to training.”

Fatuma is a Women’s Extension Worker Coordinator for the Afar Pastoralist Development Association, with a total of 12 WEWs in her team. Image: Kate Holt / Anglican Overseas Aid

Fatuma is a Women’s Extension Worker (WEW) for the Afar Pastoralist Development Association, and coordinates a team of 12 WEWs in her area.
Image: Kate Holt / Anglican Overseas Aid

Afar Region in north-eastern Ethiopia is dominated by the Danakil depression in the north, which is largely desert scrubland with shallow salty lakes and long chains of volcanoes. In the south, the Awash River flows into the northern lakes rather than to the sea. Much of Afar is below sea level and it is one of the hottest places on earth, with temperatures higher than 50°C in the summer. About 90 per cent of the regional population base their livelihood on livestock rearing – cattle, camels, goats, sheep and donkeys – with limited agriculture along the river basins and low-lying riverine areas.

The Ethiopian Ministry of Health acknowledged in Health Sector Development Program IV (2010/11-2014/15) that there was a lack of appropriate health service delivery packages to address nomadic and semi-nomadic communities in Afar Region.

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Providing water in Naibor: building businesses in return

This post was written by Loretta Pilla, an Australian volunteer who is currently working in Kenya as a Program Management Officer with Anglican Overseas Aid’s The Road Less Travelled project.

Jchabure Lengunya is a mother of six children between four and 16 years of age. In addition to her family responsibilities, she is also an active member of the Naibor Water Committee. With Jchabure’s youngest child wrapped tightly around her neck, we sit beneath the shade of an acacia tree 50 metres uphill from the recently built rock water catchment in Naibor group ranch, in Laikipia County of Kenya.

“We are now entering the wet season,” she explains, pointing at the vast red clay landscape stretching to the horizon. It is barely flecked with green foliage, with even less houses in between.

Before the water catchment was built the women of Naibor travelled long distances during the wet season to the Naibor open spring to dig for water, and even further during the dry season to the Nanyuki River.

Image: Loretta Pilla / Anglican Overseas Aid

Women of Naibor in Laikipia, Kenya, wait to collect water from the tank at the base of the rock water catchment built by the community with support from The Road Less Travelled project. Image: Loretta Pilla / Anglican Overseas Aid

Jchabure explains that the water committee is responsible for ensuring the sustainable use of water by community members. This is an important role given the pressures the harsh weather conditions and often extended dry seasons can have on water availability.

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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 work of the community

This post was written by Chris McKeon, Writer and Production Assistant at Arete Stories.

About three hours north of Nairobi around a high, rocky hill is a collection of small huts. They are part of the Maasai community of Naibor, in Kenya’s Laikipia region.

As well as the mud huts, there is also a small primary school built of metal sheeting and a track, carved through the red dust, linking it to the towns of Nanyuki and Doldol. The odd goat grazes along the side of this track and women can be seen trudging through the red dust daily with water containers on their backs. The lack of water in the community becomes increasingly apparent the closer one gets.

The dusty track that links the Maasai community of Naibor to the towns of Nanyuki and Doldol.  Image: Matthew Willman / AOA

The dusty track that links the Maasai community of Naibor to the towns of Nanyuki and Doldol.
Image: Matthew Willman / AOA

“We were in difficulties with water,” explains James Supa as he sits on a rock near the roadside. “In the dry season, mothers have to walk to the river or Doldol or Nanyuki for water. It can take a whole day to fill their buckets with water.” (Read our earlier blog post about the effects of the water burden on women in Naibor.)

The little water they do find is often contaminated by animals or can only be reached by digging in the mud where the river used to flow, five kilometres from Naibor. Supa acts as a link person between The Road Less Travelled project (TRLT) and the Maasai, to ensure any development activities are locally-appropriate and meet the needs of the community. TRLT is a project of Anglican Overseas Aid, which works in partnership with local organisation the Mothers’ Union of the Anglican Church in Kenya (MUACK).

In Naibor, the community identified the chronic water shortage as a key development challenge.  Image: Matthew Willman / AOA

In Naibor, the community identified the chronic water shortage as a key development challenge.
Image: Matthew Willman / AOA

Women of Naibor at a community meeting. The new rock catchment will mean less time walking long distances to collect water for their households.  Image: Matthew Willman / AOA

Women of Naibor at a community meeting. The water shortage is a burden that is felt most heavily by women, whose task it is to walk long distances on a daily basis to collect their household’s water.
Image: Matthew Willman / AOA

The past few years have seen increasingly long dry spells in the Laikipia region, and the water shortages have worsened. When TRLT started and a community development committee was formed, the people of Naibor identified the chronic water shortage as a key challenge, and appealed for support from the project to alleviate the problem.

After community discussions, the suggestion was made to use the local environment and build a rock water catchment to store water during the rainy season. TRLT supported the initiative, which made use of local labour and resources to build two low walls along the hill’s bare rock face, as well as a storage tank. The walls channel the rainwater down the rock face and into the tank for use during the long dry season, when water is scarce.

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Keeping pastoralist children in school during drought

In the past few months, relief has come in the form of much-needed rain to many drought-stricken districts in the Afar region of northern Ethiopia. Following an extreme dry season in 2012, and two previous years of minimal rainfall, the need for rain was critical in communities that are supported through The Road Less Travelled (TRLT) project.

Before the rains, 24 water distribution trucks were being used in an effort to avert thirst. Many Afar communities were weakened by severe malnutrition, animals were too weak to collect and carry water for households, and communities were unable to reach markets and sell stock as the animals were too emaciated. There was a strong fear that livestock would die en masse, leaving thousands of households destitute.

Between March and May, rainfall in some areas has replenished water storages, however, much of the water is unprotected and highly exposed to contamination. This leads to an increased risk of waterborne diseases among an already vulnerable community. Health extension workers have been working with project-trained health workers to establish community-level sanitation, which is a huge challenge in itself given the Afar nomadic lifestyle.

Rain has provided temporary relief for some communities in the drought-stricken Afar region of northern Ethiopia in recent months, while other areas remain dry.
Image: AVI / Fran Noonan

Other areas remain dry, having received minimal rainfall in recent months, and communities have been forced to move far from their homelands in search of grazing lands for their livestock. With the health of the herd at the heart of the pastoralists’ livelihood, TRLT partner the Afar Pastoralist Development Association (APDA) continually monitors these conditions and supports displaced communities through animal feeding and treatment, and water distribution.

A flow-on effect of the drought is that many pastoralist school children are forced to abandon their studies. Continue reading

Baseline Report offers important insight into maternal and child health among nomadic pastoralist communities

Between January and May in 2012, The Road Less Travelled (TRLT) project undertook a maternal and child health (MCH) baseline survey among Maasai and Samburu nomadic pastoralist communities in Laikipia and Samburu, Kenya.

The purpose of this baseline assessment was to understand the existing context and situation prior to the implementation of TRLT project initiatives in Kenya, and to identify the current status of key thematic areas that impact on MCH outcomes among nomadic pastoralists.

TRLT AACES Baseline Report

Maternal and child health baseline survey among Maasai and Samburu nomadic pastoralist communities in Laikipia and Samburu, Kenya.

A broad holistic strengths-based approach was adopted during the design of the project to include a focus on the key determinants of health. The thematic areas captured in the baseline study reflect this focus, and include:

  • Knowledge, attitudes and practices in relation to core MCH indicators;
  • Family planning
  • Disease and immunisation;
  • Access to health services;
  • Access to literacy and education;
  • Water, sanitation and hygiene (WASH); and
  • Livelihoods.

A quantitative questionnaire was administered to 800 pastoralist households across Laikipia and Samburu. The questionnaire was administered to a man and a woman from each of the participating households. Qualitative data was also captured via a series of focus group discussions with men, women and traditional birth attendants.

The findings allow for a deeper understanding of the knowledge, attitudes and practices regarding MCH and other issues impacting on health in these communities. This data will be used to inform The Road Less Travelled’s project strategy and set baseline evaluation indicators by which impact and change in the communities will be measured over time.

Download the full report