Effects of Family Conversation on Health Care Practices in Ethiopia: A Propensity Score Matched Analysis

"This study adds to the evidence base that involving husbands and mothers-in-law, as well as pregnant women, in behavior change communication interventions could be critical for improving maternal and newborn care and therewith lowering mortality rates."

In Ethiopia, a relatively traditional society, family power structures can have a negative effect on health outcomes, such as by impacting decisions to seek services for mothers and newborns at critical times. Studies have found that community health workers who are deployed at the grassroots level can be well positioned to discuss deeply rooted religious and cultural practices that are risky to newborn and maternal health. This cross-sectional study examines one component of the Last Ten Kilometers (L10 K) Project called the Family Conversation, an informal meeting between a health worker and several household and community members who potentially play a role in decision-making around the care of a pregnant woman and/or her newborn.

As detailed here, L10 K's foundational community strategy was carried out in 115 woredas (districts) of 4 agrarian regions (Tigray, Amhara, Oromia, and Southern Nations, Nationalities and Peoples (SNNP) regions) of Ethiopia. Developed as part of the project, the Family Conversation strategy was implemented in 3,070 kebeles between late 2013 and early 2014. A Family Conversation is a health education session organised by a health extension worker (HEW), usually together with a Women's Development Army (WDA) team leader, at a pregnant woman's home. The conversation is designed to engage close family members and relatives of the pregnant woman, creating an opportunity to discuss issues such as birth preparedness and essential newborn practices with all the family members together. The conversation consisted one visit when a woman was 4-6 months pregnant and another when she was 8-9 months pregnant. If the HEW/WDA noticed any potential barriers in the family for the intended behaviour, she arranged extra visits to conduct further dialogues or reinforce messages.

The researchers used cross-sectional data from a representative sample of 4,684 women with children aged 0-11 months from 115 districts collected between December 2014 and January 2015. They compared intrapartum and newborn care practices related to the most recent childbirth between those who reported having participated in a Family Conversation during pregnancy and those who had not. Propensity score matched (PSM) analysis was used to estimate average treatment effects of the strategy on intrapartum and newborn care practices.

The study found that about 17% of the respondents reported having had a Family Conversation during their last pregnancy. The PSM analyses show that exposure to Family Conversations had statistically significant (p < 0.05) associations with higher institutional delivery, early postnatal care, clean cord care for the newborn, and thermal care for the newborn. The treatment effect for thermal care of the newborn showed the highest effect - 16 percentage points (p = 0.001) - followed by the effect for early postnatal care (12 percentage points). Average treatment effects of 7 and 9 percentage points, respectively, were found for institutional deliveries and clean cord care (p < 0.05).

The researchers point to the significance of the fact that, in the majority of cases (80% of the time), husbands attended Family Conversations at their home. They write: "Even though their approval and decision is critical in seeking maternal and newborn health care services, husbands are not usually engaged in routine maternal and newborn health-related communication interventions...Family Conversations create an opportunity to engage those household decision makers to help improve care seeking practices in maternal and newborn health care." The participation of grandmothers and mothers-in-law in the conversation sessions was relatively low when compared with that of husbands, and the researchers suggest that, had there been high participation of grandmothers, the intervention could have had stronger effects.

In conclusion: "With many maternal and newborn care practices higher in the group of participants that had a Family Conversation, the study results suggest that, despite strongly embedded cultural and traditional practices, Family Conversations could potentially play a crucial role in changing a family's behaviors towards better maternal and newborn care practices and should be further explored."