APDAs Innovation Maternal Health FINAL DRAFT online distribution

An Overview of APDA’s Innovation in Pastoralist
Maternal and Reproductive Health

The main goal of the Afar Pastoralist Development
Association’s (APDA) reproductive and maternal,
newborn, and child health (RMNCH) program is to
reduce the severely high maternal and infant mortality
rate in the Afar community, in line with the objectives of
Millennium Development Goal 5. The program aims to
improve maternal and child health by increasing female
education participation and eliminating harmful
traditional practices in Afar Region, Ethiopia.
APDA’s maternal health program has for over a decade
delivered primary health services with a focus on safe
motherhood and sexually transmitted disease (STD)
prevention to the pastoral population of Afar Region. A
particular focus has been placed on ending the harmful
traditional practices, which include female genital
mutilation (FGM), that endanger a woman in her
reproductive years and especially during the birthing
process. APDA’s extensive experience in the area of
maternal and child health provides an opportunity for
identifying the achievements and challenges of the
program and improving RMNCH services for Afar
pastoralists by sharing the results with partners, the
regional government, and other organizations.
The research team conducted a rigorous assessment of
APDA’s Safe Motherhood program and obstetric
hospital in Mille in order to define the scope of the
Foreword
This assessment is commissioned by IGAD, the Intergovernmental Authority for Development, for
the purpose of documenting the achievements and best practices of the Afar Pastoralist
Development Association’s maternal and child health program. It provides useful insights that will
contribute to improving maternal and child health for the pastoral Afar community that can be
replicated in other pastoralist societies.
program, evaluate the progress made towards program
goals, assess the impact in the community, and define
how APDA manages the program with partners and
stakeholders. The assessment also describes challenges
in attaining program goals and highlights lessons
learned, innovations, and good practices. In particular,
the assessment focuses on the program activities aimed
at reducing the very high maternal mortality rate and
eliminating the harmful traditional practices that harm
the mother in her reproductive life, specifically those
that endanger both the mother and the child in the
birthing process.
We sincerely appreciate the work of the research team
and cooperation of all informants and interviewees. We
hope that this report will be of value to policy makers
and provide valuable insights into improving maternal
and child health in the Afar community as well as other
pastoralist societies.
Aleksandra Oldak
Ibiro Oudoum
& Research Team
Afar Pastoralist
Development Association

RMNCH reproductive, maternal, newborn, and child health
APDA Afar Pastoralist Development Association
FGM female genital mutilation
HTP harmful traditional practices
TBA traditional birth attendant
WEW women extension worker
MPHW mobile primary health worker
HIV human immunodeficiency virus
Abbreviations
PhotobyKristoffKrackenhardt

1. Introduction 1
Maternal Health 1
Maternal Health in Afar 2
2. Methodology 6
3. APDA 7
History 7
Safe Motherhood 8
4. APDA’s Best Practices 12
5. Achievements 19
6. Lessons Learned 21
7. Conclusion 23
8. Bibliography 25
Contents

Introduction
More than half a million women die each year due to complications during pregnancy and
childbirth. 95% of these deaths occur in developing nations. Most maternal deaths are preventable
through adequate nutrition, proper health care, family planning, the presence of a skilled birth
attendant during delivery, and emergency obstetric care. However, maternal mortality is not only
a failure of the healthcare system, but also a failure in guaranteeing women’s rights. (1)
1 An Overview of APDA’s Innovation in Pastoralist Maternal and Reproductive Health
Research has shown that a number of factors contribute
to maternal and newborn health outcomes. The outcome
of pregnancy is most directly influenced by the health
status of the woman, her reproductive status, and her
access to and use of health services. Socioeconomic and
cultural factors have a direct influence on these
determinants. A woman’s status in her community,
education level, income, and her access to information
and resources all affect the choices she makes about her
reproductive health. Harmful practices including early
marriage and female genital mutilation (FGM) further
increase the risks to women and babies.2
Evidence shows that pregnancies that are too early, too
close together, too many, and too late in life increase the
risk of maternal death.2
Complications during pregnancy
or childbirth are one of the leading causes of death for
adolescent girls.1
They are more likely to develop
hypertension, anemia, and prolonged or obstructed
labor. Women over the age of 40 are 7 times more likely
to die in childbirth than women in their 20s. A short
birth interval also increases the risk of maternal death.
Women who become pregnant less than six months from
their last birth are more than twice as likely to die than
women with 18-23 months between pregnancies. A
woman who has had five or more pregnancies also has a
high risk of dying from pregnancy related
complications.2
Maternal Health
Undernutrition contributes to 1 in 5
maternal deaths...
Good nutrition and disease prevention is essential before
and during pregnancy to ensure a healthy mother and
baby. Iron deficient anemia, for example, can endanger a
mother at the time of delivery. Undernutrition
contributes to one in five maternal deaths and also leads
to underweight babies and poor childhood growth which
can have permanent adverse effects into adulthood.
Infectious diseases such as malaria, HIV, and TB are
also associated with an increased risk of maternal and
infant death.3
For this reason water and sanitation, food
security, and livelihood opportunities are essential for
success in delivering maternal and child health
initiatives.4
There is evidence that inadequate and poor quality
maternal health care is associated with high maternal
mortality. The World Health Organization (WHO)
recommends a minimum of four antenatal visits during
pregnancy which pose an opportunity for improving
maternal nutrition and teaching women about the danger
signs of pregnancy complications. Most complications
cannot be predicted or prevented as the majority of
maternal deaths occur during labor, delivery, or within
the first 24 hours after birth. Therefore, the location of
women when they deliver, presence of a skilled birth
attendant, and accessibility to emergency obstetric
services are essential to preventing maternal deaths.2
A short birth interval increases the risk
of maternal death...

Girls need a healthy start in order to ensure a healthy
future. Good nutrition, immunization, and hygiene are
necessary from birth and throughout adulthood. Women
and girls must be protected from traditional practices
that harm their reproductive health such as FGM and
they need educational, nutritional, and psychological
support before they become pregnant. A skilled
attendant is essential at childbirth for both mother and
baby because the risk of death and complications is
greatest at that time. Mother and child health must be
monitored for at least six weeks after childbirth to
prevent and treat problems and ensure good mother and
child care.1
These are essential to improving maternal
health and reducing the countless preventable deaths of
mothers and infants.
An Overview of APDA’s Innovation in Pastoralist Maternal and Reproductive Health 2
Girls need a healthy start in order to ensure a healthy future
Gender inequalities often result in the low status of
women and girls, poor access to information and care,
early age of marriage, and restricted mobility all of
which result in poor maternal health. Therefore,
promoting gender equality has an important role to play
in preventing maternal deaths. Furthermore,
empowering women has been shown to increase their
use of family planning services, antenatal care, and safe
delivery in health facilities.1
The majority of deaths occur during
labor, delivery, or within the first 24
hours...
Photo by Kristoff Krackenhardt

Maternal Health in Afar Region
Afar Region in Northeast Ethiopia is one of the hottest
and most arid places in the world with temperatures
reaching up to 50° C during the hot season. It is home to
1.5 million Afar nomadic pastoralists who specialize in
herding cattle, goats, sheep, and camels. Food and water
are scarce and living conditions difficult, making
maintaining the herds a challenge. Many households
must move 2-3 times per year in search of water and
pasture. Due to their mobility and remoteness to
settlements the community has little opportunity for
accessing essential services including health and
education. As a result the literacy rate is extremely low
and many traditional beliefs and practices are adversely
affecting the health and wellbeing of women and girls.4
The Afar community adheres to a strict patriarchal
system in which clan elders govern all social, economic,
and environmental practices. Traditional association
leaders handle disputes while religious leaders play an
advisory role in and conduct marriage, divorce, and
funerary rites. Women have a low status in the
community and little autonomy. They are considered the
property of the male head of their households and of
their clan. Women’s value lies in their fertility and the
labor they provide the household. In contradiction of
Islamic teaching, they often have no choice in marriage
and few rights. To ensure marriageability, FGM is
practiced as a way of guaranteeing virginity at the time
of marriage and loyalty to the husband.4
The interaction of these social, economic, and
environmental factors has resulted in poor maternal and
child health within the Afar community. Women
perform the majority of household chores which include
carrying water for long distances and grinding grain.
Traditionally, they eat only what remains after all of the
males of the household have finished. These practices do
not change even during pregnancy as there is little
awareness on safe motherhood.7
As a result, 43.5% of
Women’s value lies in their fertility...
Afar women are underweight and 40.4% anemic.5
Undernutrition and excessive workload predispose Afar
women to poor maternal health outcomes. The Afar
maternal mortality rate in 2005-2006 was reported to be
7,947 per 100,000, or 1 out of 12.7
Childbirth is attended by family members or traditional
birth attendants and the majority of women deliver at
home (93%) due to challenges in accessibility and
acceptability of formal health institutions.6
A lack of
transportation and difficult geography pose major
barriers to reaching health facilities as well as the
presence of male staff. There is also a lack of awareness
about the benefits of delivering in a health facility and
how to identify warning signs at the time of delivery.4
A number of harmful traditional practices (HTPs)
surround childbirth and the postpartum period, posing a
risk of injury or death for both mother and child. Food
and water are withheld from laboring women due to a
belief that the uterus and bladder are connected. Once
the baby is delivered the mother is bled from the
umbilical cord to eliminate what is believed to be bad
blood.7
This severely endangers the life of the mother as
postpartum blood loss in excess of 500 mL requires
emergency intervention. For severely anemic women,
blood loss of even 200–250 ml can be fatal. Women
often delay initiation of breastfeeding due to a belief that
colostrum poses a danger to infants, instead giving the
infant a sugar water mixture and butter. Often other
liquids are introduced during the first six months of life
instead of exclusive breastfeeding.4
Traditionally mother
and child are bathed once and then not again for up to
seven days. Reclosing of the FGM scar is also common
and women are bound with rope at the thighs to facilitate
closing of the wound, posing risks for infection and
future complications in childbirth.7
93% of Afar women deliver in their homes...
43.5% of Afar women are underweight...

The use of family planning methods among Afar couples
is almost nonexistent due to religious and cultural
beliefs. Afar believe that child bearing should be
initiated early and that couples should have many
children to help with the household chores.4
The
initiation of menstruation is considered indicative of a
girl’s readiness for marriage. The practice of early
marriage preserves gender inequalities and the low
status of women in the society by disrupting girls’
education. It can lead to a heavy domestic work burden
and puts girls in danger of domestic violence as well as
poor maternal and child health outcomes.4
Early initiation of childbearing, short birth interval, and
high parity endanger Afar women in pregnancy.
Undernutrition, excessive workload, lack of water and
sanitation, limited access to education and economic
opportunities, and harmful traditional practices are all
factors that adversely affect maternal and newborn
health outcomes in the Afar pastoral community. These
factors are driven by gender inequalities.
Malaria and diarrhea are two major causes of death
among Afar children. The under 5 mortality rate is
estimated at 12.5%.5
The use of treated mosquito nets
and seeking treatment for high fevers for suspected
malaria varies, but remains inadequate. There is also a
lack of awareness about the causes and treatment of
diarrhea and studies show that many families withhold
fluids when children are sick instead of administering
oral rehydration solutions. Many families seek treatment
from traditional healers over health workers due to
convenience and affordability. Furthermore, vaccination
levels in Afar are the lowest in Ethiopia, with only 8.6%
children aged 12-23 months being fully vaccinated,
raising the risk of illness or death from preventable
diseases.5
Early initiation of childbearing, short
birth interval, and high parity
endanger Afar women...
Afar women perform 85% of the daily household chores

Methodology
Key sources of data:
 organization documents including program
proposals and plans, quarterly reports and related
documents
 program managers, staff, mobile workers, and Mille
hospital staff
 beneficiaries from the community, especially child
bearing aged women
The team used the following data collection methods:
 document, file, and literature review
 direct observation
 key informant interviews
 community based semi structured interviews
Methods and Tools Used For Data Collection
The assessment used a mix of methods for data
collection and analysis. While a formal quantification
was not possible, the qualitative data collected provides
insights into the level of success achieved by the
program and the impact in the community.
The assessment team developed a set of 6 questions to
guide the data collection process, analysis, and report
writing. Information on the program’s effectiveness,
factors that contribute to success, constraints and
challenges, lessons learned, and suggestions were
elicited.
Topics related to the Afar Pastoralist Development
Association’s Safe Motherhood program’s specific
activities included mother and child care, antenatal and
postnatal care, assisting deliveries and referral of
mothers-at-risk to the hospital, eliminating and
preventing harmful traditional practices, and disease
awareness and prevention.
The assessment team conducted an in depth review of
the program’s documents using a structured protocol, the
analysis of which informed the development of other
data collection tools. The document review established
the scope of APDA’s Safe Motherhood program and
was used to interpret the program from a broader
context.
During field visits the assessment team gathered
additional information through direct observation of
program activities using a structured observation guide.
Key Informants were identified as individuals with an
above average knowledge of the topic from first-hand
experience. These included program managers and
coordinators, women extension workers, Mille hospital
staff, and health workers involved in referral to the Mille
hospital.
Beneficiaries voiced their own opinions on the impact of
the program in their communities. Interviews focused on
the participants’ perceptions of benefits from the
program and positive changes in their lives as a result.
Methods and Tools Used For Data Analysis
Data analysis was guided by the 6 assessment questions
and sub questions developed for data collection.
Descriptive analysis was used for data collected from the
document review in order to understand the context in
which the program evolved, the scope of the program,
and how the program remains dynamic. Content analysis
was the main method used for qualitative data gathered
from interviews and discussions to identify themes,
common trends, and diverging views.
To check and establish the validity of the findings the
team used data and methodological triangulation. When
possible, different investigators were involved in the
analysis of findings.

APDA
The Afar Pastoralist Development Association is a community based organization founded by
members of the Afar community. The organization’s vision is that the “Afar pastoralist community
through its own motivation will direct its development with full emphasis that Afar women are
involved in maximum participation”. ADPA has been working with Afar pastoralist communities in
Ethiopia for over 20 years.
first looks at behavior change within it’s membership as
well as mainstreaming the issues of gender equality in
all training and job descriptions.
APDA recognizes that in order to facilitate development
in the society all activities must be aimed at correcting
the consequences of the gender imbalance that has led to
the low status and resulting poor health of Afar women.
APDA seeks the ongoing guidance of pastoral women
through the organization’s annual conference of pastoral
women where they voice their grievances and give
APDA feedback on program activities.
In 1994 APDA launched the organization’s Primary
Health program in Afar Region with the objective of
lowering death from preventable diseases. Six topics
were chosen for voluntary workers to teach the
community about and the team of Afar health workers
walked house to house raising awareness, treating
illness, and tracking disease. In a region with less than
2% literacy and where no social services had been
available before female reproductive health was the
most affected by the under-developed health system. As
a result, APDA’s overall strategy to reduce maternal and
infant death became fundamental to the program. Afar
literacy was introduced as a catalyst for behavioral and
social change.
In 1999, as the program continued to develop, a special
role was created for Afar women to become agents of
social change and implementers of primary health within
their own communities. These women extension
workers (WEW) work alongside APDA trained
traditional birth attendants (TBAs), mobile primary
health workers (MPHWs), and Afar literacy teachers in
a multi-sectoral effort to improve maternal and child
health in Afar Region.
The program remains dynamic with APDA reviewing
progress and achievements in quarterly meetings and
with the community refining strategies and
implementing innovations.
The organization’s chief advantage is that the vast
majority of the members and workers are from the
community itself. With an extensive gender policy it
History
APDA’s Approach
holistic: the program includes HTP awareness and
mobilization occurring within all sectors and
features multiple approaches,
participatory: APDA empowers the community to
lead their own development and all community
workers are Afar
human rights based and culturally sensitive: safe
motherhood and elimination of HTPs are human
rights and supported within the framework of
Islam, the program aims to improve gender equity
and preserve positive cultural values while
eliminating harmful practices
strategic and dynamic: the program is reviewed
and refined quarterly, adapting to emerging needs
and community feedback

Safe Motherhood Within APDA
Improving maternal and child health where multiple
cultural and economic factors play a role requires a
holistic approach and it is for this reason that APDA
integrates multiple sectors into the Safe Motherhood
program. The program aims to:
 Lessen women’s workload in daily household
chores
 Stop the harmful practices that predispose women to
poor health and well-being
 Empower Afar pastoral women to be implementers
of development change within their society
The main strategy driving these objectives is increasing
female education participation.
Lessen women’s workload in daily household
chores
Afar women perform 85% of all household daily chores
including those that are essential such as collecting
water, grinding grain, collecting firewood, and making
food. Women must sometimes walk several kilometers
to reach a source of water and then return carrying the
15-25 liter container strapped to their backs. Grinding
grain for one meal can take up to 2 hours by hand.
Women are also responsible for dismantling and
rebuilding the mobile house when the family changes
location. This heavy workload takes a toll on women’s
health and overall wellbeing as they have little time to
rest and eat. APDA works to lessen women’s burden in
these daily tasks through:
 Advocating for husbands to share their daily work
burden, in particular teaching that any pregnant
woman should not carry heavy loads
 Constructing rain-water harvesting reservoirs to
make water more available
 Installing grinding mills
 Encouraging mobile shops or household shops to
make needed commodities more available
Women are trained in income generating activities and
encouraged to form associations for support and
collaboration. They also help other women in the
community get involved in income generating activities
through APDA’s microfinance program.

Stop harmful practices that predispose women
to poor health and wellbeing
APDA’s main strategy in eliminating harmful practices
affecting pastoralist women is to empower local
communities through culturally appropriate education. A
particular focus is placed on including girls and women
in the process. APDA also campaigns for women’s
rights in marriage, which is traditionally arranged, and
can have severe consequences when girls run away or
attempt suicide. Particular attention is given to those
harmful practices that affect women’s reproductive
health, such as FGM and reinfibulation, and the
practices that can harm mother and child during
childbirth.
APDA trains and mobilizes multiple actors in this effort:
 Traditional birth attendants are former FGM
practitioners trained in safe delivery practices and
mother and child care
 Women extension workers are local women trained
and empowered to promote good practices and
advocate for women
 Religious leaders are engaged to defend the rights of
women through Islam
 Community committees are responsible for
monitoring the stopping of harmful practices
Facilitate Afar pastoral women to be
implementers of development change within
the society
A special community development role is placed on
women extension workers. These literate pastoralist
women are empowered as implementers of development
change and work within their own community. Women
extension workers mobilize the community in health and
sanitation, advocate for women’s rights, and facilitate
social and behavioral change. They encourage women
and girls to take part in education and advise women on
income generating opportunities.
In 2011 APDA opened the Barbara May obstetric
hospital in Mille. It is the first fully equipped emergency
obstetric care facility in Afar region. Mille was chosen
specifically for it’s central location. The hospital serves
as both a referral hospital and training institution for the
region. Equipped with 28 beds for in-patient care and an
operating room it is a vital addition to APDA’s program
in safe motherhood. Built for Afar women it is staffed
with Afar health workers and features traditional Afar
housing for rural women who are uncomfortable with
modern facilities. The hospital is linked to the
community through mobile primary health workers and
traditional birth attendants. Afar women are referred to
the hospital when mothers-at-risk are identified during
antenatal visits and in the case of obstetric emergencies.
APDA’s Obstetric Hospital
PhotobyAleksandraOldak

APDA enlists the support of religious leaders in the effort to eliminate
FGM. Koranic teaching and the hadiths support the need to stop this
harmful practice:
 A woman with FGM is unable to properly clean herself since the
urethra is closed over by scar tissue
 A woman performing FGM has the blood of an innocent girl on
her hands and must seek forgiveness or face judgment.
 As a last resort the FGM practitioner who refuses to stop
performing FGM can be charged with a crime as FGM is illegal
according to the Ethiopian Constitution and Criminal Code.
91.5% of Afar
women have
undergone
FGM
Confronting Female Genital Mutilation

APDA’s Best Practices
A holistic approach ensuring water & sanitation, food security, livelihoods, and education
Empowering Women Extension Workers as agents of development change
Training Traditional Birth Attendants as prime actors in safe motherhood
Working with the regional government and religious leadership
Using film and music to mobilize the community and involve youth
The poor state of maternal health in Afar is a result of
multiple social and cultural factors interacting with a
challenging environment. For this reason APDA
employs a holistic approach in delivering safe
motherhood by deploying multiple sectors in the effort.
Increasing female participation in education is the
foundation of the safe motherhood program. Studies
have shown that women with higher levels of education
have better maternal health, less children, and more
access to economic opportunities. Girls who are in
school are also more likely to marry later and to use
family planning methods to delay pregnancy.3
Linked to
APDA’s mobile education program, WEWs work with
mobile literacy and education teachers to ensure that
women and girls are participating in education
opportunities in their communities.
Women with economic literacy and assets have a greater
ability to control and negotiate household resources and
also the freedom to make choices regarding their own
health.3
Afar women’s economic dependence is a major
barrier to safe motherhood. APDA trains women in
income generating activities and provides loans through
microfinance for startup of businesses such as mobile
shops and marketing activities. Enabling women to
participate in economic activities not only benefits the
household, but also is a stepping stone to social change.
For this reason APDA facilitates the formation of
women’s income generating associations within the
community. These women then train others in economic
literacy and basic business management.
Water and sanitation and food security are vital to
maternal and child health outcomes. Communities need
access to water suitable for drinking to prevent disease
and to ease women’s workload of collecting and
carrying water back to the household, especially in
pregnancy. Diarrhea from poor sanitation and dirty
water is one of two main causes of under five child
mortality rate in Ethiopia. APDA ensures water security
in communities through the installation of rainwater
harvesting systems and dams. Besides reducing
malnutrition and thirst, animal survival is increased and
therefore the livelihood of Afar communities is secured.4
The community is fully involved with all of APDA’s
programs and the programs are tailored specifically to
suit the community. As a result APDA is well received
by the communities it works in. The safe motherhood
program is guided and assessed by community feedback
in quarterly meetings.
A Holistic Approach

WEWs: Agents of Change
Women extension workers are Afar women selected by
their own communities for training by APDA.
Empowered to be implementers of development change
these women teach basic health and hygiene and
mobilize their communities in eliminating harmful
traditional practices. They serve as advocates for
women’s rights and a catalyst for social change. News of
their efforts has travelled by word of mouth and they
have become so renowned for the impact they make in
their communities that APDA receives requests for the
training of WEWs in areas where the program has not
yet been implemented.
APDA chooses literate women specifically because of
the extensive work that WEWs perform. In the event
that there are no literate women in the community, the
selected women first undergo literacy training. They are
then trained to raise awareness on hygiene and
environmental sanitation, good nutrition, care of
expectant mothers and infants, HIV prevention, and how
to mobilize the community in stopping harmful
traditional practices. WEWs are also responsible for
training traditional birth attendants in safe delivery
practices and monitoring their activities.
A great emphasis is placed on raising awareness on the
prevention of disease.
In their assigned areas WEWs visit every household
once each month. They are trained to perform rapid
nutrition assessments and teach families about a
balanced diet. The control of anemia is one of the most
effective ways to prevent complications during
pregnancy and childbirth. To address the high rate of
anemia among Afar women, they teach the community
about the importance of including iron rich foods in the
diet and demonstrate how to cook lentils and chickpeas.
Because malaria is a major threat to pregnant women
and small children WEWs supply the community with
mosquito nets at a low price. They also sell soap that is
produced by APDA and teach about the importance of
hygiene in preventing disease transmission.
Particular attention is paid to expectant mothers and the
special care they need. WEWs advise pregnant women
on proper nutrition and the dangers of doing heavy work
in pregnancy. Men are encouraged to help with
household chores and ensure their wives get an adequate
diet. WEWs also perform antenatal and postnatal checks
along with the TBAs. Together they identify mothers in
high risk pregnancies and refer them to Mille hospital
Medina Ali
woman extension worker 11 years
“We are called women extension workers and
we teach people what APDA has taught us...
we teach the community how to prevent
disease.. For this reason they welcome us into
their homes and send us to teach women
about safe motherhood.”
WEWs are a powerful force of social change...

The traditional birth attendant is an essential member of
the Afar community. She is not only experienced in
childbirth, but crucial for opening the FGM scar that has
covered the passage to the birth canal. She also performs
FGM and recloses the open wound after childbirth.
Traditional birth attendants are the prime actor in
maternal care in the Afar community and it is for this
reason that APDA recruits and trains them in safe
motherhood and child care. Particular emphasis is placed
on antenatal care and abandoning the harmful practices
that endanger mother and child during childbirth and
throughout their lives.
To ensure good health from the start, APDA trained
TBAs visit women throughout their pregnancies,
performing antenatal checks and recording the mother’s
condition on a form. They teach women about essential
hygiene and also advise them on good nutrition during
pregnancy and breastfeeding. Trained in the normal and
abnormal symptoms of the trimesters of pregnancy, they
identify mothers-at-risk and refer them to the hospital in
Mille. They also report all births, deaths, and the
outcomes of all deliveries in their area.
TBAs: the Prime Actors
for delivery. WEWs also provide the TBAs with APDA
made clean delivery sets for each birth.
WEWs play an vital role in addressing social issues.
They counsel women with marriage problems and notify
local religious leaders when cases of forced marriage
arise. In order to break the cycle of female economic
dependence WEWs assist and advise women on income
generating opportunities and encourage women and girls
to take part in education. They also organize community
meetings to address these issues and to raise awareness
on the importance of eliminating harmful traditional
practices.
WEWs are a powerful force of social change in the
community. Their power is twofold. First, they are
women transformed from passive bystanders to agents
of change. APDA’s training empowers these women to
not only take development into their own hands, but also
to examine their own lives and advocate for change that
will bring the community out of hardship. Second,
because these women are working in their own
communities they are personally invested in their work.
Amina Ibrahim, APDA Gender Officer

A number of harmful practices associated with
childbirth can lead to injury and death. APDA trains
TBAs to identify and agree to stop these harmful
practices. These include FGM, reinfibulation,
withholding food during labor, bleeding the mother to
eliminate ‘bad blood’, and delaying breastfeeding and
washing of mother and child. Instead, practices that
benefit the mother and child are introduced. During
labor the mother is given plenty of liquids and food that
will sustain her strength and keep her hydrated. A clean
delivery set is used for each birth along with a new razor
blade. Once the baby is delivered the umbilical cord is
cut, cleaned with a salt water solution, and wrapped in
TBAS are the prime actors in maternal
health in the Afar community...
gauze. The infant is wrapped in a warm blanket and
mothers are instructed to breastfeed immediately.
Mother and child are bathed and monitored over the next
few days.
APDA trained TBAs are vital to improving maternal
health as they are the prime actor in maternal care within
communities. They are crucial in the effort to eliminate
FGM as they themselves were once practitioners.
Intimately aware of the complications resulting from
FGM, they are empowered to take a stand against the
status quo and advocate for women’s health. With their
new knowledge these women take pride in the care they
give mothers and their babies.
APDA trained TBAs are vital to promoting
safe motherhood....
Photo by Kristoff KrackenhardtAPDA trained TBA performing an antenatal examination.

Working With Local Leadership
APDA coordinates with the regional government and
enlists the support of local and religious leaders in
promoting safe motherhood and eliminating harmful
traditional practices.
APDA has a long history of partnership with the
regional government. Vaccination campaigns and
emergency relief activities are coordinated with the local
health bureau as APDA often has access to remote areas
that other organizations do not. APDA’s network of
community workers links with the government in the
Mille hospital referral system. The government provides
emergency transportation to Mille hospital by
ambulance when women suffer complications in
childbirth.
The regional government also plays an important role in
the campaign against FGM. The Ethiopian Constitution
prohibits the practice of FGM and the criminal code
allows for practitioners to be fined or imprisoned along
with parents who subject their children to the procedure.
As a last resort, FGM practitioners who have refused to
stop the practice can be charged with a crime and fined.
Religious leaders are vital to confronting FGM as people
mistakenly believe that it is a practice mandated by
religion. Sheiks teach the community that there is no
Fatuma Abdulkadir
traditional birth attendant, Teeru
“In the past when we were in darkness...
There was suffering. FGM caused us much
suffering in childbirth. Pregnancy was a
death sentence and only God could help us.
It is a bad practice...FGM”
mention of FGM in the Quran and only a few weak
hadiths that actually advise people to limit the practice.
In light of other Koranic verses that prohibit altering or
harming the human body, the local religious leadership
has taken a stand with APDA and the regional
government against any form of FGM. APDA employs
several sheiks who guide this effort.
When women and girls are forced into marriage or
married before they’ve reached the age of consent the
local Sharia (Islamic court) is notified. The religious
authorities warn people of the illegality of such
marriages within Islam. In the case that the Sharia fails,
local law enforcement is informed and the marriage
annulled. Marriage before the age of 18 is illegal in
Ethiopia.
Working with local leadership strengthens the effort in
eliminating harmful traditional practices and promoting
safe motherhood. Religious leaders are a fundamental
resource for improving women’s health as Islam
requires that women and their children receive all of the
care and support they require.
Sheiks teach the community that FGM is
not mandated by religion...

Using Film and Music to Raise
Awareness
APDA has its own musical band and drama group who
perform songs and raise awareness on issues including
FGM and forced marriage. APDA workers visit
communities and show films depicting the hardships
caused by harmful practices. A number of messages are
conveyed including the importance of HIV testing and
encouraging men to help their wives with household
chores, especially during pregnancy. A generator is used
to power band equipment and projectors. This allows the
campaign to reach remote rural areas where exposure to
mass media and government campaigns is minimal.
The musical band and drama groups have proven to be
very popular as Afar culture is rich in oral traditions and
the medium relatable for the community. This effort is
particularly effective in getting youth interested and
involved in the campaigns to eliminate harmful practices
and promote safe motherhood. One of the films shown
includes actual footage of a young girl undergoing
FGM. Since many people have little knowledge of the
procedure they are deeply disturbed by the footage. The
use of shocking images, especially with unseen practices
like FGM, is effective in changing people’s attitudes and
the first step in achieving behavioral change.9
Men are especially affected by the images in the FGM
film. Some men even become physically ill at the sight
of blood and the amount of flesh being cut. The showing
of such sensitive topics in film provides a way to initiate
community discussion on issues that are otherwise
taboo. Men become furious with women when they see
how the procedure is done in the film. Women respond
that it is the men who desire girls to be circumcised. At
this point the community begins to question where this
practice came from and why they have been doing it.
Mohammed Adan
APDA Health Department Head
“APDA is the only organization that has
access to the very remote areas of Afar
region. We take a generator to power a
projector and show awareness raising
films to the community. These are
about FGM and proper hygiene and
sanitation.”
Men are especially affected by the FGM film...
PhotobyDerejeGirma

Women extension workers teach women about the importance of following
good nutrition and proper hygiene in order to prevent disease. They also
counsel women with marriage problems and raise awareness about HIV.
APDA WEW teaching about proper hygiene in child care. Photo by Kristoff Krackenhardt

Achievements
Mille Hospital is Saving Lives
APDA’s obstetric hospital is the first of its kind in Afar
Region. It provides a clean and safe place for Afar
women to deliver and get medical care for reproductive
health issues. Although the hospital opened with a slow
start it’s reputation has grown and women are coming
from as far as other regions to seek care from the highly
qualified staff. To date, the hospital has seen more than
3,000 women in two years’ time. A number of volunteer
doctors and health workers from overseas have served
in the hospital since it’s opening.
Besides providing a safe place for Afar women to
deliver, the hospital sees many patients for
gynecological issues and a complications resulting from
FGM. Many young girls have received corrective
surgeries for injuries that have resulted in urine
retention. Patients receive education on the harmful
consequences of FGM, the importance of vaccination,
and family planning. The hospital also works with the
community to raise awareness on maternal health
through workshops in Mille.
Dahara Ali, Qaddaqar
“I thought I was going to die and so I wanted to
die at home. Now I know better. That’s the
reason I refused the hospital at first....
They really know what they’re doing.
They know how to care for women.
They examined me and checked on the baby.
After they gave me an ultrasound and listened
to the baby the doctor assured me that he was
fine.”
The hospital also serves as a training institution for local
health workers. Within the local education system nurses
and midwives receive a lot of theoretical training, but
virtually no practical experience. The hospital puts all
locally hired staff through an extensive training system.
Dr. Margaret McDougald, a volunteer from the United
Kingdom, has set high standards for hospital staff that
are not common in Ethiopia. Ibrahim, the hospital
manager expressed that he believes it is the best hospital
in Ethiopia
The hospital also conducts research on disease
prevalence and attitudes towards health within the
community. A survey was conducted to identify the
reasons Afar women were hesitant to visit health care
facilities. Another study has found that Hepatitis B has
significant prevalence within the community despite the
little attention this preventable disease has received from
government awareness raising campaigns.
Patients receive education on safe motherhood...
PhotobyDerejeGirma

Great strides have been made in APDA’s efforts to
eliminate FGM from Afar region. Infibulation, the most
severe form of FGM, has been almost universally
abandoned. Mobile primary health workers now record
the FGM status of young girls in routine vaccination
campaigns.
Preliminary data show that there has been a significant
decrease in the practice. In Gewane, for example, health
workers have reported that 60% of girls aged under 1
year have not been undergone infibulation. The 2005
Ethiopian Demographic and Health survey found that
92% of adult Afar women had undergone any type of
FGM and 63% had been infibulated. 85% of women had
at least one daughter with FGM, 74% of whom had been
infibulated.10
This shows a significant decline in the
practice as most often the procedure is done within 10
days of birth. The few isolated cases that occur are
investigated by APDA’s workers and the family visited
to reveal why they are continuing this harmful practice.
For the first time in Afar region, 5 young women known
to be uncircumcised have been married in Gewane. It
was previously believed that uncircumcised girls were
unmarriageable within the Afar community. This event
shows that the attitudes which were perpetuating this
practice are in decline.
Ending FGM Improving Maternal Health
Women extension workers, traditional birth attendants,
and mobile primary health workers stand together in the
effort to improve maternal health within the community.
APDA aims to train at least five TBAs in each kebele.
At 1136 TBAs trained to date, the program has seen
enormous success in the campaign to educate the
community in good practices during childbirth.
In 1999 APDA trained the first group of 20 women
extension workers and sent them into the community.
Today 286 women extension workers are monitoring
their community’s health and nutrition status and caring
for women throughout pregnancy.
APDA’s maternal health messages have reached the
community. Women are following proper dietary
guidelines and avoiding heavy work throughout
pregnancy. They are doing this with their husbands’
support:
A man in Qaddaqar was seen carrying a large bag of
grain along the road. When questioned, he explained that
his wife was 6 months pregnant and he had gone into
Mille to bring her some household supplies. He
explained that Afar women used to do this work, but
now that the community has seen the consequences, they
have no choice other than to change this tradition.
“We are working on eliminating harmful
traditional practices day and night.
With our religious leaders, clan elders,
the education committee, and with the
women extension workers we go house
to house. This is how we raise awareness
on stopping FGM.”
Traditional Birth Attendant
PhotobyDerejeGirma

Lessons Learned
Geography is a Barrier to Accessibility
Afar Region covers a large geographic area with a
sparsely distributed population. Some 85% of Afar are
rural and nomadic. This presents significant challenges
to delivering any type of social services to the
community. APDA’s network of mobile primary health
workers, women extension workers, and traditional birth
attendants together provide basic health treatment and
referrals to health centers and Mille hospital in the event
of emergencies. The problem is that many women facing
complications in childbirth arrive at the hospital too late.
In the event of an emergency communication can be
difficult as many Afar do not own mobile phones and
network coverage is limited, especially in rural areas.
Remote areas lack roads or have roads that are in serious
disrepair. Many Afar settlements are only accessible by
foot due to difficult terrain or obstacles such as rivers.
Transportation also poses a challenge as few Afar own
vehicles. Women must be transported by camel to the
nearest town or carried on a stretcher. If they are able to
find a vehicle they must pay for fuel and sometimes pay
the driver as well.
Awareness and Acceptability
Due to their lack of experience with the formal health
care system Afar women are reluctant to visit health
centers for the treatment of illness and unlikely to seek a
skilled attendant during childbirth. Any resulting death
or injury is attributed to the will of God. An estimated
93% of Afar women deliver in their own homes.5
45.6% of Afar women surveyed believe that delivery in
a facility is not necessary.5
There is little awareness that
many complications in pregnancy can be prevented or
treated if women comes to the hospital for antenatal
checking and for delivery.
Childbirth is a private matter in Afar culture. 41.2% of
women surveyed said that delivery in a facility is not
customary.5
Health centers and hospitals are
uncomfortable for Afar women as they have little
experience with these types of facilities. Many women
also dislike being attended by male staff.
Lack of acceptability of services is another reason
women often arrive at Mille hospital too late.
A large geographic area with a sparse population is a barrier to accessibility

FGM is a Complex Issue
FGM is a practice that is deeply rooted in cultural and
religious beliefs. Although there has been a notable
decrease of new cases of FGM in many communities,
some areas have replaced infibulation with the less
severe ‘sunna’ practice, which includes partial or
complete removal of the clitoris and sometimes the labia
minora. This lesser practice does not exclude the
immediate possible consequences of FGM including
shock, severe pain and blood loss, infection, and the
emotional trauma that results, especially when
performed on older girls. Women who have undergone
any type of FGM have a higher risk of complications
during childbirth than women who have no FGM.11
Although people are aware of the harmful effects of
FGM on women’s reproductive health, changing their
attitudes about women and gender roles has been more
difficult. When asked whether their own children had
undergone FGM many people replied that they had not.
Upon further questioning it was revealed that instead
‘sunna’ had been performed.
This replacement of infibulation with a lesser form of
FGM reveals that the deeply ingrained attitudes about
women as overly sexual beings whose sexuality is to be
controlled and exploited by men still exist.
Men tend to believe that FGM is a beneficial practice,
especially for the purpose of preserving a girl’s virginity
and thereby securing her marriageability. The majority
of men prefer to marry a girl who has been circumcised.
Social acceptance is another reason men believe it is
beneficial. A man in Qaddaqar woreda explained:
“We’ve abandoned infibulation. We do ‘sunna’ instead.
If it’s not cut, the clitoris will rouse women from their
sleep.”
People feel an overwhelming sense of obligation to
adhere to the traditions that are deeply rooted in culture
and religious beliefs. In a tightly knit and strictly
governed community, deviance from these traditions is
met with stigma and shame. Girls who are not
circumcised may be ostracized by their peers and
community. Girls may be in favor of the practice
because they do not want to be stigmatized, and perhaps
unable to marry.
Although a legal process exists for charging perpetrators
with a crime, this route is not effective. Clan elders
often intervene and the family is pressured into using
the traditional system of settling disputes, which favors
reconciliation above all else.12
“It was a different time for my
children. We thought it was good, but
it’s not...FGM. My granddaughter has
not been circumcised.
For Afar, an uncircumcised
girl is disgraceful.”
Fatuma Humad, Qaddaqar
PhotobyDerejeGirma

Conclusion
The state of maternal health in communities is
intrinsically linked to the social and economic status of
it’s women. Any efforts to improve maternal health must
address the underlying gender inequalities within that
society. Ensuring women’s rights to autonomy,
education, and economic activities all have been shown
to improve women’s reproductive health. They also
allow women more participation in decision making,
specifically in making decisions regarding their own
health. It is for this reason that reducing the maternal
mortality rate and improving women’s reproductive
health must be considered from a human rights
perspective, the basic right to life.
People’s livelihoods, food security, and access to clean
and safe water are also vital in any maternal health
initiatives. When a community struggles in poor health
from a shortage of food and lack of water, they are
unable to adopt any of the awareness raising messages
they have received. Ensuring a potable water supply
decreases the burden of women’s daily workload and
maintains animal health. For pastoralists this is vital as
their livestock are their livelihood.
Ensuring safe motherhood and eliminating FGM
requires a fundamental shift in the gender status quo.
Men must be engaged in the process as they are often
against the continuation of the practice of FGM. Men
and women must engage in dialogue in order to bring
these hidden attitudes into the open. Only with dialogue
will we one day see a generation of girls that aren’t cut
simply because they were born female, that don’t fear
the night of their wedding, and can welcome the birth of
their first child with joy instead of fear that they may not
live through to the next day.
The Way Forward
Accessibility is a known barrier to maternal health in all
of Ethiopia, not only Afar Region. APDA is beginning
the implementation of a three-tier system which links
women with higher level facilities. This system features
a series of satellite waiting areas and Mille hospital at
the center. Women with high risk pregnancies will be
referred by TBAs to health centers staffed by trained
midwives. These waiting areas will feature Afar
traditional housing where the mothers can comfortably
give birth. Health center staff will be trained in
identifying danger signs in childbirth and refer
complicated cases to Mille hospital. This system will
bring basic maternal and child health care services to the
rural community.
To raise the community’s acceptability of the formal
health care system APDA plans to continue raising
awareness about the benefits of visiting the hospital
during pregnancy through it’s community-based
workers. WEWs and TBAs have already made progress
in raising awareness on the prevention of illness and are
referring women to the hospital. As women learn that
skilled Afar staff work in the hospital and that traditional
housing is available, the number of women seeking
skilled assistance in delivery will increase. Women
extension workers have been discussing family planning
methods that are compatible with Afar cultural and
religious beliefs.
After achieving community acceptance of abandoning
FGM III and recording a notable decrease in the
practice, APDA is seeking to eliminate the less severe
form as well. Mobile primary health workers conducting
community vaccination campaigns are now checking
and recording every girl’s FGM status. This is recorded
on her vaccination record. Any households who have
continued the practice receive more attention from the
harmful practices team and those who have performed
infibulation are targeted specifically for intervention.

“We are getting some relief from the oppression we had
before. If we continue to teach people...
I see a brighter future ahead...”
Momina Uddo, women extension workers trainer

Bibliography
1. Paul Hunt and Judith Bueno de Mesquita, Human Rights Centre, University of Essex. Reducing Maternal
Mortality: the contribution of the right to the highest attainable standard of health. December 2012.
2. UNFPA. Addis Ababa, Ethiopia. Trends in Maternal Health in Ethiopia, December 2012
3. DFID. Choices for women: planned pregnancies, safe births and healthy newborns. Glasgow, UK. 2010.
4. Anglican Overseas Aid. The Road Less Travelled. Ethiopia. Maternal and child health baseline survey
among nomadic pastoralist communities in the Afar region of Ethiopia. 2012.
5. Central Statistical Agency [Ethiopia] and ICF International. 2012. Ethiopia Demographic and Health Survey
2011. Addis Ababa, Ethiopia and Calverton, Maryland, USA: Central Statistical Agency and ICF
International.
6. Key Informant Interviews, community interviews, and direct observation undertaken in October –
November 2013.
7. APDA program documents and quarterly reports.
8. WHO. Policy Brief: Effects of Female Genital Mutilation on Childbirth in Africa. Geneva, World Health
Organization (WHO). 2008.
9. Sehin Teferra. Tackling tradition: examining successful strategies in the mitigation of female genital
mutilation in Ethiopian communities.
10. Central Statistical Agency [Ethiopia] and ORC Macro. 2006. Ethiopia Demographic and Health Survey
2005. Addis Ababa, Ethiopia and Calverton, Maryland, USA: Central Statistical Agency and ORC Macro.
11. WHO, ‘A systemic review of the health complications of female genital mutilation including
sequelae in childbirth’. WHO/FCH/WMH/00.2. Geneva, World Health Organization (WHO),
2000.
12. Alem, E., Hailu, E., Siyoum, H., Sesay, I., Mitik, L., Suyama, M., et al, 2013, ‘Evaluation of progress with
using community conversation as a strategy to encourage district level abandonment of female genital
mutilation and/or cutting in 10 districts in Ethiopia’, African Evaluation Journal 1(1). Art. #11, 10 pages.
http://dx.doi.org/10.4102/aej.vi1i.11

The Afar Pastoralist Development Association
P.O. Box 592 Code 1110
TEL. 011-5-15-97-87
EMAIL afarpda@gmail.com
WEB www.apdaegtiopia.org
Supplementary Film:
“Innovations in Maternal Health”
Afar Video Production
December 2013
This publication was made possible through financial support
from the Intergovernmental Authority for Development (IGAD).
An Overview of APDA’s Innovation in
Pastoralist Maternal and Reproductive Health
December 2013
Cover photo: Kristoff Krackenhardt
Aleksandra Oldak
aoldak@asu.edu

APDAs Innovation Maternal Health FINAL DRAFT online distribution

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