Women and Children First has successfully completed the first test of its personalised health appointment calendar system in Goro Woreda, Ethiopia. 839 pregnant women benefitted from the innovative scheme, resulting in an increase in women attending antenatal care appointments and being supported through childbirth by a skilled birth attendant.
The project results show that the calendars are feasible, acceptable and accessible. The project, implemented with our partners Doctors with Africa CUAMM, could potentially have further impact in other countries and rural communities.
Across rural Ethiopia only 17% of women can attend antenatal care in the first trimester, a crucial stage in the baby’s development and to identify risks for the mother.
Many women in rural communities have no access to mobile technology and struggle to access healthcare information and keep track of all their recommended appointments.
The charity trained local community health workers to identify pregnant women in their area and visit them to tailor personalised wall calendars. Based on the date of their last period, they use a ‘contact calculator’ to identify the dates for their antenatal appointments, their due date, postnatal care and their baby’s vaccinations.
These dates are then given to the woman on a personalised calendar, hung on the wall of her home. They are presented clearly, with stickers showing what dates a particular appointment is.
Through Health Management Information Systems data and focus group discussion feedback, the charity understood what worked with the project.
Rahmat, one of the women who received the calendar in their home
Improved Antenatal Care
Receiving antenatal care at least four times, with the first contact in the first 16 weeks, increases the likelihood of receiving effective maternal health interventions during the antenatal period. This can be critical for the wellbeing of the mother and baby.
Yet traditionally, women in Ethiopia – as is the case in many other countries - are reluctant to announce or reveal their pregnancies before the end of the first trimester. This makes it difficult to initiate antenatal care early.
The calendar and the project resulted in improved uptake of antenatal care appointments and services. This included a 17% increase in women attending 4 or more antenatal care contacts.
Chart showing an increase in 4+ antenatal contacts (before the project: 25%; after the project: 42%) and more women receiving an antenatal contact in the first 16 weeks of their pregnancy (before the project: 6%; after the project: 14%)
Even more encouragingly, the data shows an 8% increase in women attending antenatal care within the first 16 weeks of their pregnancy.
In addition to the calendar, conferences were held at ten central villages in the project area. These provided health education on the importance of disclosing pregnancies early on to a health worker, including to screen for life-threatening conditions and to check the baby’s health.
One of the women benefitting from the project said, “After we got the calendar, we made use of antenatal care services and we gained knowledge by following it. Our interaction with the health professionals improved and improved our awareness to call an ambulance.”
Encouraging The Use of Skilled Birth Attendants
With calendars in women’s homes and encouragement from their community health workers, there has been a 9% increase in women receiving skilled care during the delivery of their babies.
A chart showing the increase in deliveries by a skilled birth attendant before the project - 42% - and afterwards, 51%
One mother said, “I called an ambulance when my delivery approached, on the basis of the calendar, and safely returned home with my child.”
Other Achievements
100% of women who were offered a calendar accepted them, showing a high level of interest in the calendar and the support it can provide during pregnancy.
Women commented on how the calendar was an acceptable, useful tool to remind them of their appointments before, during and after birth.
A mother said, “It helps to easily remember the day of our appointment, get ready for delivery, and date of immunisation of our child.”
Another mother remarked, “Before the calendar we forgot our appointment as we are busy with household chores, now we can easily remember our appointment and go to the health post.”
A third added, “It encourages me to regularly follow my appointments and access health services for myself and my baby.”
A community health volunteer interjects, “The women feel happy when we post the calendar at their home. They are happy when we follow up with them and they welcome what we explain to them about the services. Family members also show interest.”
One of the mothers enrolled in the scheme, with the calendar hanging on the wall of her home
The calendars were found to be useful by the community health volunteers, as well as the mothers. The accompanying diary was a helpful tool to plan their routine home visits when they are most needed, while the calculator helps them accurately and easily assign appointments.
All women mentioned the information on the calendar was easy to access. They mentioned that the colours were attractive, the health messages were clear, and the size of the font was legible.
“It is good. The different colours pass different messages and I know the purposes of the colours on the calendars. It is visible when it is hung on the wall.”
Low or no literacy women mentioned that they were supported by their husband, children, their neighbours, or health workers to help access the information on the calendar.
One stated, “The calendar was not difficult to understand but because I am not educated my children read it for me.” Another agreed, “My husband helps me in reading the dates of my appointment and advises me to follow my appointment.”
Areas for Improvements
It has been hard to assess the impact the calendars have had on postnatal care. While there has been a 5% increase in women seeking care within 7 days of delivery, it is hard to attribute how much of this has been down to the calendar initiative or a change in policy. Health workers are now tasked to conduct postnatal care visits at home, rather than at a health post or facility.
Similarly, it has not been possible to gauge the uptake of vaccinations and immunisation for the children. This is in part due to the length of time the project was running, with many parents’ children not reaching one year of age and full immunisation by the project end.
Anecdotally there has been a positive response, with one mother saying “I used this calendar and now I have a 7-month-old infant and on right track of scheduled immunisation. I didn’t miss any appointments.”
The charity has received useful feedback to help develop future iterations of the calendar. This includes about the design of the calendar itself, with comments such as “Calendars are ruined with smokes and dusts for most of the mothers living in huts” – suggesting lamination will help.
Another remarked, “The sticker size is big and sometimes covers the particular calendar date and should be smaller in size.”
Pregnant women and their community health workers had difficulties in identifying the dates of their last period, which affected their confidence in using the calendar and wheel. This is not uncommon, and the system had been built-in with buffer times.
Refresher training was conducted to help overcome this challenge and provide reassurance – and as a result, can be addressed more explicitly earlier in the roll-out of the project.
Some women faced challenges accessing health services, highlighting the importance of strengthening health service delivery simultaneously while helping create demand for them.
What’s Next?
The success of this first phase provides evidence for progression to a second phase. The aim of this will be to demonstrate the causality of the work to reduce maternal, newborn and child mortality at a larger scale, for a longer time, with more rigorous evaluation.
There is potential for further success in Ethiopia, or other settings where community health workers are tasked with door-to-door visits to pregnant women to promote uptake of antenatal, delivery, postnatal and immunisation services.
Women and Children First is seeking funding and partners to further develop the calendar initiative, enabling more women to have safe deliveries and their children to survive and thrive.
Ultimately, attendance at antenatal care, delivery with a skilled birth attendant, attendance at postnatal care, and uptake of immunisation could save over 2.6 million lives every year.