Ethiopia has reduced maternal and infant mortality rates in recent years. But women at the margins – those experiencing inequitable gender norms, low literacy, social and geographic isolation, poverty, and other challenges – continue to experience poor maternal and birth outcomes.
A 2024 pilot program, led by Johns Hopkins Professor Rajiv N. Rimal and the Johns Hopkins Center for Communication Programs (CCP) team in Ethiopia, suggests a new way forward: Addressing the challenges by improving men’s support for women during pregnancy and delivery.
Supported by the Gates Foundation, CCP worked with pregnant women, their husbands and other stakeholders to design a solution – the Supporting Health and Reproductive Equity (SHARE) intervention – that uses real-life stories to model couples working together to overcome barriers to prenatal care and giving birth under the help of trained health professionals in safe and sterile facilities.
“When given the opportunity, pregnant women in Ethiopia will voice their needs and work together to create innovative solutions that address those needs,” says CCP’s Tewabech Tesfalign Sheno, who directs the SHARE project in Ethiopia. “Our human-centered design approach gave women the confidence to envision solutions that would lead to better outcomes for themselves and their families.”
During home visits, community health workers used a specially designed screening tool to identify couples at high risk for poor outcomes. These couples were then equipped with an audio device featuring pre-recorded real-life stories with prompts for discussion.
The intervention worked: Men’s supportive behaviors increased by 31 percent over four months of intervention in Oromia region, which includes the capital, Addis Ababa. Men were more involved in making decisions about health, saving money for services, accompanying their wives to health facilities, and doing household chores. Among women, the frequency of prenatal care visits nearly doubled, and 12 percent more women gave birth in a health facility, which is safer than delivering at home.
One mother in rural Ethiopia, Rahmete, praised the intervention. She had given birth at home several times and suffered from excessive bleeding, but after listening to the audio with her husband: “I went to the health facility and gave birth to a healthy baby.”
“Ensuring that as many women as possible give birth in a health facility is a noble goal and it is a challenge of health systems in many countries,” Rimal says. “Now that we have developed an intervention that clearly works to improve maternal health outcomes, we just need the financial support to make it available to more Ethiopians.”
Women in Ethiopia work hard taking care of their households and doing activities outside of home. Often, as delivery nears, they must add the extra tasks of preparing for the feasts and celebrations that will come when the baby does. Often the men are not fully engaged in household chores. Yet husbands are primary decision makers for most major household level decision including healthcare expenses.
Better spousal communication is crucial in improving male partner engagement in household chores and supporting pregnant women’s uptake of prenatal care and health facility delivery services.
One unintended benefit of the pilot program, Rimal says, was learning that men really do want to be involved, but given social norms, “they’ve not had an avenue on how to do it.”
“But when we find ways of bringing them closer to household tasks, what we’re learning is that they actually enjoy it, and they do it, and they are proud of it,” he says.
Expanding the intervention could improve uptake for perinatal and post-partum services. By increasing access to the full continuum of maternal health services, women will experience a host of benefits – micronutrient supplements that improve birth outcomes, options for birth spacing and family planning, lifesaving obstetric care during delivery, and more.
The leaders of SHARE say that a $1 million grant for one year would expand the intervention to at least 100,000 women in 10 Ethiopian woredas. A $5 million grant for three years could reach 750,000 women in 75 woredas, taking economies of scale into consideration.
Based on the results of the pilot evaluation and other research, CCP’s Habtamu Tamene Temesgen, senior director of research monitoring and evaluation in Ethiopia, says he expects this would increase institutional delivery by 15 percent and utilization of prenatal and post-partum care by at least 50 percent.
Says Rimal: “If we can expand SHARE, more women will survive childbirth, improve their nutritional status, achieve their desired family size and birth spacing intervals, and enjoy greater health decision-making power.”
The audio technology used in the pilot, which is essentially a pre-recorded radio, also pulled husbands into the fold. “It gave them a reason to stay at home, to listen to what was being said, and feel more comfortable discussing issues with their wives that would not have come up otherwise,” Sheno says.
Rimal says that future iterations of SHARE should consider updating the technology, perhaps to cell phones, but he recognizes that many women in these rural areas don’t have access to them and that this population should continue to be a priority.
“I think something that we will forever be chasing is this very highly vulnerable group that is not reached by other mainstream interventions,” he says, “There have to be interventions specifically targeted to their living conditions, where they live, how they live, their level of poverty, etc. We really have attempted to reach that group in this project, to reduce the gap between the folks who have access to other means and those who have access to no means.”